Foreign body in the appendix presenting as acute appendicitis: a case report

The year 1735 saw the first appendicectomy, which was performed on an 11-year-old boy at St. George’s Hospital in London by Claudius Amyand during which a sewing pin was found to have perforated the appendix [6]. FBs in the appendix are uncommon but well described with an estimated prevalence of 0.0005 % [7, 8]. FBs generally do not cause any complications and pass through the gastrointestinal tract (GIT) spontaneously within a week. The complication rate of ingested FBs is estimated at less than 1 % [8].

Various objects acting as FBs have been reported in the literature to be the cause of acute appendicitis, including bird shot, bullets, fishing lines, screws, coins, stones, toothbrush bristle, pins, needles, teeth, bone fragments, dog hair, fruit seeds and pits, toothpicks, drill bits, tongue studs, crown post, keys and intrauterine contraceptive devices [3, 4, 7–11]. Considering the dependent position of the cecum and to some extent its low motility, such FBs tend to gravitate and settle there. In addition, the chance of entry to the appendiceal lumen is determined not only by its orifice (which might be tight or widely open) but also by the anatomic position of the appendix. There is almost no possibility for a FB to enter the lumen of a retrocecal appendix [8]. Once the FB is lodged in the appendix, peristaltic motion is usually insufficient to expel it back into the cecal lumen. It may remain immobile in the appendix without stimulating an inflammatory process or cause an inflammatory reaction with or without perforation. The period of latency between ingestion of the FB and the onset of symptoms varies from hours to years [4, 9, 11]. Complications usually depend on the size and shape of the FB. Blunt FBs cause appendicitis through obstruction of the appendiceal lumen and remain dormant for longer periods. Elongated sharp FBs are more likely to cause perforations, appendicular abscesses, and peritonitis [4, 8–10].

In our case, there was no history suggestive of FB ingestion during clinical evaluation. However, following retrieval of the condom fragment from the patient’s appendix and its presentation to the patient postoperatively, she could recall having performed oral sex on her boyfriend 2 weeks prior to the onset of symptoms. She reported that the condom had loosened during the act and she accidentally ingested it. She however did not find it necessary to inform us as she did not think it was the cause of her symptoms because she had passed out fragments of the ingested condom in her feces 5 days after ingestion. It is likely that during its migration in the GIT the condom was torn into fragments and a piece was trapped within the vermiform appendix and the rest expelled in fecal matter. Arya et al. [12] had reported a case where multiple pieces of a condom were retrieved from the bronchus of a 27-year-old Indian woman. As in the present case report, she inhaled the condom during oral sex.

Apart from accidental ingestion of a condom during oral sex, it is important to note that the act is also associated with several other complications including a significant risk of transmission of human immunodeficiency virus, syphilis, herpes, chlamydia, hepatitis viruses, gonorrhea, and human papilloma virus infections [13].

There is a need to increase awareness of the potential dangers of ingested FBs. Each time such incidents occur, it is advisable patients report promptly for proper evaluation and follow-up until the FB is properly traced as it may account for significant morbidity and mortality.