A girl of 15 presented to the hospital with suspected appendicitis. The appendix is a vestigial remnant of intestine, full of lymphoid tissue. No one is sure what it does. About seven percent of people develop appendicitis in their lifetime.
The appendix can become blocked, causing inflammation, and if unchecked, it will rupture. It may be blocked by a fecalith, a very small hardened mass of feces mixed with calcium salts, which frequently traverses the bowel. The chance of dying is low, and is more likely to occur in patients who wait too long before going to the hospital.
Appendicitis has protean clinical presentation and mimics many other conditions. The classic symptoms are nausea and anorexia, with crampy midabdominal pain. The most telling part of the history is migration of the pain from the area around the umbilicus to the right lower quadrant of the abdomen.
Patient Tamara had a 3 day history of abdominal discomfort. She also complained of nausea with vomiting and, according to her mother, had developed a fever. On exam, she was mildly febrile, with pain in the right lower quadrant and a positive Rovsing sign.
A diagnosis of appendicitis was suspected. Surgery was scheduled. At Tamara’s surgery, there was no reason to expect anything more than a routine procedure. The appendix was easily visualized by the surgeon. It was normal except at the very tip, which was inflamed. It is odd for only a portion of the appendix to be inflamed since it’s usually all or nothing. The tip was adherent to a loop of bowel against which was stuck a fallopian tube and ovary. It was as if a piece of blood-red bubble gum was responsible for this gaggle of organs, sticking them together in an inflammatory mass. As the dissection was extended, pus escaped from the incision. An abscess had formed, explaining the girl’s symptoms and physical findings.
As the pus drained, and the area was cleansed with saline, a cylindrical object popped into the surgical field. Where had it come from? It was an empty black 35 mm Kodak film canister with its characteristic gray lid. Its path was tracked on exam, and was found to have migrated through the vaginal wall into the abdomen, where it had formed the abscess and mimicked appendicitis.
Postoperatively, the surgeon awaited an explanation from the patient. How had an empty film canister found its way into the belly of his young patient?
An embarrassed teenager recounted how 3 years previously, she had inserted the film canister into her vagina in an effort to conceal menstruation. She had been unable to retrieve it, and simply forgot about it. It waited 3 years before reappearing.
From “The Woman Who Swallowed a Toothbrush,” by Rob Myers, M.D.
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