ABDOMINAL SURGERY

Official Journal of the American Society of

Abdominal Surgeons, Inc.

This article originally appeared in the Winter 2013 / Spring 2014 issue of the
Journal.

Diverticulum in Small Bowel with

Foreign Object

Steven Behrends, M.D.1 Address for correspondence:

John R. Dobson, III M.D.2
Stephen Larsen, Ph.D.3
Frederick Larsen, B.S.4
Ferris Buhler, B.A.5
Stephen Larsen, Ph.D.
Department of Pre-Clinical Sciences
Cleveland University
10850 Lowell Ave.
Overland Park, KS 66210
Tel: 913-234-0763
Fax: 913-234-0904
E-mail: stephen.larsen@cleveland.edu

1 General Surgery, private practice, Kansas City, Missouri

2 Pathology, Saint Luke's South Hospital, Overland Park, Kansas
3 Professor, Pre-Clinical Sciences, Cleveland University, Overland Park, Kansas
4 Analytical Chemist, Independence Police Forensic Laboratory, Independence, Missouri
5 Intern, Cleveland University, Overland Park, Kansas

SHORT SUMMARY
This case involves surgical removal of a foreign object sequestered in a jejunal
diverticulum. The object was determined to be silicone rubber. Subsequent surgery
revealed multiple jejunal diverticuli with chronic diverticulitis, which may have masked
long-standing symptoms of celiac disease.

ABSTRACT
Acute abdominal emergencies may prove to be a diagnostic conundrum. Imaging can
identify regional anatomy; however, anatomic variations can confound the specific
diagnosis. Surgical intervention revealed a jejunal diverticulum containing a foreign object
with the potential for perforation. Histological studies provided information regarding
tissue alterations due to the presence of the foreign object and for classification of
diverticulum type. Chemical analysis of the foreign object was determined to be
polydimethylsiloxane. A possible link between the patient's long-standing symptoms from
previously diagnosed celiac disease and the presence of a biologically inert foreign object
is discussed. Literature related to the ingestion of foreign objects is reviewed.
KEY WORDS: jejunum, diverticulosis, perforation, polydimethylsiloxane, celiac sprue,
enteropathy

ABBREVIATIONS: FO, foreign object; GI, gastrointestinal; EGD, esophagogastroduo-

denoscopy; SI, small intestine; CT, computed tomography; H&E;, hematoxylin & eosin
stain; FTIR, Fourier Transform Attenuated Total Reflection Infrared Spectroscopy; PDMS,
polydimethylsiloxane; NG, nasogastric; TURP, transurethral resection of prostate

INTRODUCTION
The discovery of an FO lodged in a jejunal diverticulum prompted study of the anatomy,
histology, and embryology of this case. Diverticula can form in the GI tract from
esophagus to rectum, with the most common occurrence being in the colon. The
incidence of diverticula in the small bowel is low, falling within a range from 0.2% to 6%,
as found in upper GI radiographs and observed at autopsy.1,2 Two types of diverticula
occur and can be classified as true (congenital) or false (acquired). True diverticula
possess three wall layers: mucosa, submucosa, and muscularis externa (propria), present
in normal SI. False diverticula possess the two innermost layers, with the muscularis
externa being attenuated or absent.3,4 A fourth, thin serosal layer is also present on the
outer intestinal surface. Most diverticula are found on the antimesenteric border of the
SI.2 It has been reported that the frequency of occurrence of diverticula increases with
age and is more often found in males than females.5,6Most ingested foreign bodies will
pass spontaneously; however, approximately 1% will require surgical removal of the FO.7
We present a surgical case, physical and chemical analysis of the FO, and histology of the
tissues involved.

CASE REPORT
In 1995, a sixty-two-year-old, physically active, mentally alert male presented with mild
to acute gastric discomfort and weight loss, resulting in orders for a diagnostic EGD.
Duodenal tissue sections indicated blunted villi and lymphocyte infiltration in the mucosal
epithelium. Based on the histopathology and clinical symptoms, celiac disease was
reported as probable diagnosis.8 A gluten-free diet was recommended and complied with
by the patient. Major symptoms diminished with time, and weight gain followed; however,
the patient continued to experience recurring episodes of GI distress.

In 2010, the patient suffered moderate to acute pain in FIGURE 1 A&B;:

left upper and left lower abdominal quadrants and Axial CT Scan (Figure 1A)
suprapubic region. Symptoms persisted and were and coronal CT Scan (Figure
severe enough to require a visit to the emergency 1B) showing radiopaque FO
room. A CT scan revealed an FO in the lower left in lower left abdomen.
abdomen, with possible perforation of the bowel
(Figures 1A & 1B).

Following general surgical consultation, a laparotomy

was recommended to remove the FO. Open abdominal
surgery revealed the presence of a jejunal diverticulum
with an FO projecting through the wall to the outer
serosal layer. A 4- cm length of bowel was resected
click to enlarge
(Figures 2A & 2B), and a side-to-side anastomotic
bowel repair was performed. The surgical pathology
report disclosed an intestinal specimen with deep
outpouchings consistent with diverticulosis. The report
further revealed a 1.2 x 0.7 x 0.3 cm orange-yellow,
grossly apparent foreign body protruding from a 2.7 x
2.2 cm bulge in the intestinal wall. Internal inspection
of the diverticulum disclosed tan-brown mucosa
enclosing a 3.7 x 1.0 x 0.6 cm orange-yellow, rubbery
click to enlarge
FO (Figures 3A & 3B). Serial sections of the FO were
obtained and stained with H&E.; Tissue sections were
obtained from the wall of the diverticulum (Di-1).

The patient experienced an uneventful recovery and reported being symptom-free at his
6-month follow-up examination. As a result of general well-being and the absence of GI
complaints previously attributed to celiac disease, the patient discontinued his gluten-free
diet. This behavior is understandable, as the literature indicates compliance with this diet
is difficult, due to its personal and social inconvenience, expense, lower palatability, and
lack of availability.9,10

In 2011, a subsequent acute abdominal episode resulted in exploratory surgery of the

intraperitoneal SI, which revealed a 30-cm section of jejunum with multiple
communicating diverticula varying in size from 5-30 mm (Figure 4). This segment was
resected, and successful bowel repair was completed. The patient continues to ignore a
gluten-free diet and remains symptom-free. A series of tissue sections was obtained along
the anti-mesenteric length of this section to identify histologic signs of celiac disease.

FIGURE 2A: FIGURE 2B:

SI presented at surgical site with
FO projecting from diverticulum
(Di-1). A second, smaller
diverticululm (Di-2) is also
shown.
Resected bowel with affected
diverticulum (Di-1), adjacent
diverticulum (Di-2), and small
intestine (SI).

click to enlarge
click to enlarge

FIGURE 3A: FIGURE 3B:

Front and rear surface of FO. Cross section of FO.

click to enlarge click to enlarge

FIGURE 4:
30-cm resection with
communicating diverticula that
have been surgically opened.

click to enlarge

FIGURE 5a: FIGURE 5b:

FO slide with amorphous matrix Brownish stained external margin
and crystalloid aggregates, 400x. of FO, 100x. No biological cells
are observed in either slide.

click to enlarge
click to enlarge

FIGURE 6a: FIGURE 6b:

Tissue from Di-1 showing Fibrotic tissue and inflammatory
attenuated villi, extensive fibrosis cells in SM & ME, 400x.
 of SM and ME, and serositis
caused by FO, 11x.

click to enlarge

click to enlarge

FIGURE 7:
Normal villi, 40x.

click to enlarge

DISCUSSION
Physical examination of the FO revealed a pink-pigmented, elastomeric compound with
surface vesicles. These vesicles suggest a bio-film layer stained brown-green as a result
of bile salt adsorption/absorption. The inability to grossly identify the FO prompted use of
microscopic and analyticalchemical techniques to determine if the material was biological
or synthetic and to differentiate between ingestion of a foreign material and in situ
formation.11

Histological examination of FO serial sections with light microscopy revealed a

homogenous matrix with 7-50 μm crystalloid aggregates present throughout the
specimen (Figures 5A & 5B). No cellular elements were observed, ruling out a biological
origin. Samples from the FO were analyzed by infrared spectrometry and the data
compared to the spectra of a known sample of medical-grade PDMS and chemical library
spectra.12,13 The unknown sample was determined to be composed of silicone
rubber.14,15

An attempt was made to identify the source of the FO, and a patient interview ruled out
his being a "deliberate ingester" of bizarre objects.16,17 Materials usually found in
enteroliths and lacto-, phyto-, pharmaco-, or trichobezoars were absent, ruling out in situ
formation.18,19,20,21,22 The route of FO placement in the diverticulum must either have
been per os23,24 or retrograde via the rectum (per podicem), the latter being highly
unlikely.

It is beyond the scope of this paper to identify the source of the FO, however, it was of
interest to determine how long the FO was present in the digestive tract. The ability of
PDMS to resist bio-degradation is well documented25,26,27 and is generally stable within
the ranges of 2-8 pH and 34.4-37.8oC normally found in the digestive tract.28 The
presence of vesicles and slight adsorption/absorption of surface bile pigments indicates
prolonged exposure to digestive juices. Also, the rounded ends of the FO suggest it was
subjected to mechanical ablation and shaping by peristalsis over a significant period of
time.

Although relatively inert from a chemical and biochemical perspective, siloxanes can
provoke inflammation and immunologic responses.29,30 The Di-1 wall sample shows
attenuation of the mucosa, extensive fibrosis of submucosa and muscularis externa, and
the presence of serositis (Figure 6A). Areas with an increased presence of eosinophils,
lymphocytosis, and extensive fibrosis observed in Di-1 (Figure 6B) are likely due to
mechanical irritation from the presence of the FO and the physiologic action of peristalsis.

Histopathology observations of chronic inflammation and fibrosis in the diverticulum,

along with the known chemical stability of the FO, suggest that the FO was not recently
sequestered in the small bowel. Inflammation in the diverticulum could account for
chronic GI distress over a significant period of time. Although coincidental remission of
celiac disease must be considered, it seems reasonable that the FO and presence of
multiple diverticula created "mischief " in the GI tract, mimicking symptoms of celiac
disease. Serial non-diverticula wall tissue samples from the subsequent acute abdominal
surgery's 30-cm resected bowel were examined. The H&E; slide shown in Figure 7
indicates a normal structure. The lack of blunted villi and an acceptable number of
lymphocytes in the epithelial layer suggest no frank celiac disease.8

CONCLUSION
Emergency surgery revealed an FO in the process of perforating the wall of a jejunal
diverticulum. The impending perforation appears to have been provoked by blunt trauma
injury to the lower left abdominal wall. The FO was composed of synthetic PDMS silicone
rubber, a non-biological compound used in manufacturing of biomedical devices.31 The FO
entered the GI tract per os and either created a new diverticulum or entered a pre-
existing cavity.32 The diverticulum containing the FO exhibited chronic inflammation and
extensive wall fibrosis, which apparently resisted perforation for a substantial period of
time. Multiple SI wall tissue sections from regions devoid of diverticula did not show
histopathology associated with celiac disease. The GI symptoms suffered by this patient
and ascribed to celiac disease may have been caused by the presence of an FO and
multiple jejunal diverticula. FIGURE 7. Normal villi, 40x.

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