VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

Foreign Body Foes: Ingestion of Wire Bristle Grill Brush Warranting Operative Intervention Allie Kukla, OMS-III; David McCabe, MD Roper St. Francis, General Surgery, Charleston, SC.

Abstract # CBR-22

Abstract

Case

Conclusions

Foreign body ingestion is a common occurrence, but bowel perforation is rarely seen. Even more rare is bowel perforation due to ingestion of a wire bristle grill brush. This presents unique challenges as ingestion of such grill brush bristles is often unknown to the patient. A 38 year old female presented to the emergency department with three days of worsening abdominal pain, developing nausea and profuse vomiting on day three. There was suspicion for appendicitis due to right lower quadrant pain localization. A computed tomography (CT) scan of the abdomen and pelvis revealed a small linear foreign body in the distal small bowel causing perforation with no signs of obstruction. The foreign body was identified and removed via exploratory laparoscopy and the patient recovered well. The foreign body was an approximately two inch metallic wire thought to be from ingestion of a wire grill brush bristle. Small bowel perforation caused by foreign bodies is typically due to ingestion of fish bones, toothpicks, and other thin sharp items. In current literature cases of ingestion of wire grill brush bristles most frequently present with upper aerodigestive tract symptoms such as globus sensation and odynophagia. Cases causing injury to the small bowel are far less common. The number of injuries due to wire bristle grill brush ingestion continue to rise making it important for both the public and physicians to consider.

Wire grill brush bristle ingestion most frequently causes symptoms of globus sensation or odynophagia, which resulted in Wong et al. developing a treatment algorithm for possible brush bristle ingestions with migration to the upper aerodigestive tract. 5 No such algorithm exists for cases involving the abdomen. In cases where index of suspicion is high a computed tomography (CT) scan is the optimal imaging modality for detection of a metallic foreign body as it is more sensitive than X-ray. 5,6 In most cases, ingestion of a foreign body is done accidentally or due to diet, and not all patients will recall a specific inciting event. 7 It is important not to rule this out of the differential simply based on lack of patient history. Luckily, perforation of the GI tract only occurs in roughly 1% of foreign body ingestions. 7 Other cases which ingestion of wire bristle grill brushes lead to small bowel injury reported in the literature have a wide range of symptom presentation. One case involved a 58 year old male with a chief complaint of worsening halitosis who was found to have a foreign body embedded in the duodenum secondary to grill bristle ingestion 8 . Another case involved a 78 year old male with a pancreatitis like presentation who was found to have a wire bristle perforating his duodenum 9 . One retrospective review found five cases of enteric injury by metallic grill brush bristle ingestion and aimed to identify possible risk factors. In all cases the patients’ grill brushes had not been replaced in over two years 10 . No other definitive risk factors could be identified but careful cleaning of residential grills and frequent brush changes were recommended based on these results. Cases of ingested wire bristles from grill brushes working their way to the distal small bowel and causing perforation are few, yet the severity and potential complications makes it important to call attention to. This patient underwent exploratory laparoscopy with subsequent removal of the foreign body thanks to a swift workup and accurate radiological reading. With cases of wire grill brush bristle ingestion increasing, it is important to keep both the public and physicians aware of this possible foreign body ingestion.

HPI: This is a 38 year old female who initially reported vague abdominal pain. She associated this with previous UTI symptoms she had experienced and spoke with her PCP who started the patient on Macrobid. Two days later this patient presented to the ED due to severe worsening of her abdominal pain and new onset nausea, vomiting and diarrhea. The pain localized to her right lower quadrant and there were concerns for appendicitis and colitis. Medical History: Attention deficit hyperactivity disorder, Bipolar disorder Surgical History: Cervical discectomy, tubal ligation Tests and Results: Laboratory orders included a complete blood count and complete metabolic panel, both of which were unremarkable. Computed tomography (CT) scan of the abdomen and pelvis with contrast that revealed a small linear foreign body in the distal small bowel causing perforation but no signs of obstruction. Management: This finding warranted surgical consultation and the initial plan was to admit the patient for conservative management. She received fluid resuscitation with intravenous normal saline, placement of a nasogastric tube, Zosyn, and serial examinations. Due to worsening of her abdominal pain the following day the decision was made to move forward with operative intervention. Operative Management: She underwent an exploratory laparoscopy. The bowel was closely evaluated running from the ileocecal valve to the ligament of Trietz. The metallic foreign body was seen protruding from the distal ileum and carefully removed, it appeared to be a wire bristle presumably from a grill cleaning brush. Outcome: After surgery the patient's symptoms were markedly improved, vital signs and follow up laboratory studies were unremarkable. The patient was discharged home two days following the procedure.

Introduction

Table 2a. CT Coronal

Millions of Americans have grills in their backyards, but many are unaware of the injury wire bristle grill brushes can cause. In 2012 the CDC published a morbidity and mortality report regarding ingestion of wire grill brush bristles, stressing the importance of both public and physician awareness. 1 An investigation from 2002 2014 reported there were 1698 grill brush injuries warranting emergency department treatment. 2 A review of 31 grill bristle ingestion cases by Mortensen et al. found 65% were located in the oropharynx and review in 2021 found bristle localization in the abdomen occurred approximately 28% of the time 3,4 Cases leading to abdominal injury are more likely to have delayed presentation than those causing injury to the upper airway or upper digestive tract. 4 The diagnostic imaging of choice for precise location is a non-contrast computed tomography (CT). 1 The treatment for ingestion of a wire grill brush bristle can range from conservative management to surgery depending on the location and degree of injury. Here we discuss a case that warranted exploratory laparoscopy with removal of the foreign body.

References

1. Centers for Disease Control and Prevention (CDC). Injuries from ingestion of wire bristles from grill-cleaning brushes - Providence, Rhode Island, March 2011-June 2012. MMWR Morb Mortal Wkly Rep. 2012 Jul 6;61(26):490-2. PMID: 22763887. 2. Baugh TP, Hadley JB, Chang CWD. Epidemiology of Wire-Bristle Grill Brush Injury in the United States, 2002-2014. Otolaryngology – Head and Neck Surgery. 2016;154(4):645-649. doi:10.1177/0194599815627794 3. Mortensen M, Samara G, Regenbogen E. Grill-Cleaning Wire Brush Bristle Ingestion: Case Series and Review of the Literature. Annals of Otology, Rhinology & Laryngology. 2018;127(10):698-702. doi:10.1177/0003489418789178 4. Miller N, Noller M, Leon M, et al. Hazards and Management of Wire Bristle ingestions: A Systematic Review. Otolaryngology – Head and Neck Surgery. 2022;167(4):632-644. doi:10.1177/01945998211062156 5. Wong S, Brook C, Grillone G. Management of Wire Brush Bristle Ingestion: Review of Literature and Presentation of an Algorithm. Annals of Otology, Rhinology & Laryngology. 2016;125(2):160-164. doi:10.1177/0003489415599992 6. Abdul Mueed Zafar, Florence L. Chiang, Zanira Fazal, Isabel S. Bass, Grill-Cleaning Wire Brush Bristle Ingestion: Two Cases and Review of Literature with Focus on Diagnostic Approach. The American Journal of Medicine Volume 129 Issue 7 2016, Pages e61-e63. ISSN 0002-9343. https://doi.org/10.1016/j.amjmed.2016.01.038. 7. Goh, B.K., Chow, P.K., Quah, HM. et al. Perforation of the Gastrointestinal Tract Secondary to Ingestion of Foreign Bodies. World J. Surg. 30, 372 – 377 (2006). https://doi.org/10.1007/s00268-005-0490-2 8. Dedania B, Khanapara D, Panwala A, Dharan M. A Case of Mysterious Impacted Duodenal Foreign Body Presenting with Halitosis. Case Rep Gastroenterol. 2017 Jan 6;10(3):800-807. doi: 10.1159/000454709. PMID: 28203127; PMCID: PMC5260512. 9. Sulieman M, Hall MAK, Wong G, Ahmed R. When It's Not Pancreatitis, Don't Brush It Off: A Case Report of Small Bowel Perforation Caused by a Grill Brush Bristle Masquerading As Pancreatitis. Cureus. 2022 Oct 18;14(10):e30422. doi: 10.7759/cureus.30422. PMID: 36407171; PMCID: PMC9670664. 10. Sordo S, Holloway TL, Woodard RL, Conway BE, Liao LF, Eastridge BJ, Myers JG, Stewart RM, Dent DL. Small Bowel Perforations by Metallic Grill Brush Bristles: Clinical Presentations and Opportunity for Prevention. Am Surg. 2016 May;82(5):412-5. doi: 10.1177/000313481608200515. PMID: 27215721.

Table 2b. CT axial

Acknowledgements

Special thanks to Dr. Kilkenny who was the primary surgeon consulted on this case.

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