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Unusual cause for small bowel obstruction

Foreign body ingestion is a common occurrence. Although over 80% of ingestions resolve spontaneously, approximately 1% of cases will require open surgical intervention.

We present a rare case of foreign body ingestion in an 18-year-old man causing distal mechanical small bowel obstruction, requiring exploratory laparotomy and enterotomy.

An 18-year-old man with no significant medical history and no previous abdominal operations presented to a regional hospital with a 5-day history of persistent nausea, vomiting, absolute constipation and generalised abdominal pain. On clinical examination, he was tachycardic (116 beats/min) with a low-grade temperature (37.8°C), and had abdominal distension with central abdominal guarding. Plain films showed dilated loops of small bowel, consistent with small bowel obstruction.

Subsequent evaluation with a CT scan demonstrated appearance of small bowel obstruction with at least one transition point in the left lower abdomen, with features concerning for internal herniation or mesenteric torsion resulting in closed loop obstruction. No foreign objects were seen at the initial reporting of imaging. A nasogastric tube was placed and an emergency explorative laparotomy was performed for concerns of closed loop bowel obstruction. Intraoperatively, small bowel dilatation was found throughout, up to the distal ileum. A soft, fluctuant and intraluminally mobile mass of approximately 4 cm in length was palpated in the distal ileum . The mass was causing severe obstruction, and the bowel distal to this was collapsed. Enterotomy revealed a water-filled rubber balloon. No history of foreign body ingestion was given by the patient on repeat assessments postoperatively. Given the density of the water balloon, only on retrospective review of the initial CT imaging was the foreign body identified. The patient was discharged home after tolerating enteral nutrition and outpatient psychiatry review organised.

Intraoperative photo showing small bowel dilatation (green arrow) and soft fluctuant mass in the terminal ileum (red arrow).

Intraoperative photo showing water-filled rubber balloon (black arrow) and the tail of the balloon with a string attached (blue arrow).

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