Peritonitis Due to Perforation of the Small Intestine by a Press-Through-Package

Hiroomi Matsumura, Hiroshi Izumi, Hiroshi Tsuchihashi, Naoki Kakihara, Ryoji Iizuka, Keigo Miyata, Osamu Ikawa, Koji Fujii, Shigeru Takahashi and Atsushi Takenaka

Department of Surgery, Kyoto Second Red Cross Hospital

A 77-year-old man with acute onset of lower abdominal pain and generalized peritonitis showed numerous diverticula along the descending and sigmoid colon and ascites in abdominal computed tomography (CT). We diagnosed peritonitis secondary to perforation of the colonic diverticulum and conducted emergency laparotomy. The colon was intact but the small intestine had been perforated by a press-through-package (PTP) still containing a tablet. We removed the PTP and conducted wedge resection to close the perforation. Small intestinal perforation by a PTP is rarely diagnosed because most patients do not realize they have swallowed their medication with the packaging and have no specific complaints or radiologic signs. We conducted an experiment to determine the usefulness of abdominal CT in diagnosing PTP ingestion. We created a sausage-shaped cylinder as a phantom of the intestine, and was inserted an intact PTP, including a tablet in it. The phantom was immersed in a vinyl bag filled with water and CT was conducted. The PTP appeared as a triple-contrasted target lesion, consisting of high, low and slightly lower densities, corresponding to the tablet, air in the dome, and water around the PTP. This unusual sign in the intestine strongly suggests the presence of an ingested PTP and is an indication for surgery when peritonitis is present. Small intestinal perforation following PTP ingestion is relatively rare, and mostly due to carelessness. Improved design to avoid accidental ingestion, particularly in the elderly or impaired, and better training in PTP use should decrease the incidence of this problem.

Key words
press-through-package, perforation of the small intestine, phantom experiment

Reprint requests
Hiroomi Matsumura Department of Surgery, Kyoto Second Red Cross Hospital 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026 JAPAN

Accepted
December 月12, 2001

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