Ingested foreign bodies involve children, adults with mental disorders, prison inmates, and patients with dental prostheses. Ingested foreign bodies usually go throughout the entire gut uneventfully. An incidence of 0,0005% has been reported for foreign bodies found inside the ileocecal appendix. Prosthetic teeth, screws, needles, and pellets have all been implicated in this rare finding.
A few days ago, while having a fantastic lunch of hunted wild boar meat, two lead pellets were found within the meat. (Figure) Because none of us has mental disorders nor uses prosthetic teeth, the pellets were noticed and not swallowed. Eating hunted meat for several and systematic occasions is the reason for finding ingested lead pellets. Abdominal pain and lead poisoning are both possible consequences.
Orhan Ozkan et al. from Turkey reported in 2015 one more case of a 45 yo male with right iliac fossa pain for the last four months. Since he had eaten hunted rabbit several times he had ingested three lead pellets. Lead blood levels were normal excluding lead poisoning. Preoperative imaging found the pellets to be in the right lower abdominal quadrant, and during surgery they were found to be inside the appendix. An appendectomy was the definite treatment and the patient was discharged home free of symptoms.
Eating hunted meat is a risk factor for ingested lead pellets.
Foreign bodies in the appendix are rare. Claudius Amyand (London) reported the first case in 1736 in an 11 yo patient with an appendix perforated by a pin within the hernia sac. As doctors, we must keep in mind that a foreign body can stay inside the appendix for a long time without symptoms. However, acute appendicitis with or without perforation can eventually arise. In the particular case of lead pellets, besides acute appendicitis, lead poisoning can occur if many pellets are present. Patients eating hunted meat for several and repeated occasions are those at risk. This is the reason why some European countries have banned lead from the pellets. Lead poisoning (also plumbism and saturnism) can be acute or chronic (most frequent) ranging from nonspecific symptoms to encephalopathy. Some case reports have been published about lead poisoning because of pellets accumulation inside the appendix ( Zardawi et al. removed 57 pellets from the appendix of an 8 yo child). According to Orhan Ozkan et al. endoscopic removal of ingested foreign body inside the appendix is recommended whenever possible. If this is impossible to perform or if acute appendicitis is suspected, an appendectomy should be performed laparoscopically. In my opinion, an appendectomy is the best option to remove the foreign body from the ileocecal appendix.
This case report highlights how paramount a good clinical investigation is. Only by performing a complete anamnesis, doctors could suspect lead poisoning due to ingested lead pellets. Once again, complete clinical examination is the central core of a quality clinical practice.
Lead pellets can cause abdominal pain and lead poisoning.
Lead poisoning can also arise from another practice. Patients who drink from crystal bottles may also suffer from lead poisoning. Why? Because crystal bottles have lead which can slowly poison the drink inside. So, if you have drinks inside crystal bottles you have three options: 1) drink it fast so that lead has no time to poison the drink; 2) change the drink frequently; 3) use it only for decoration. If you do not want to spoil the drink, do not use crystal bottles. This is my favorite solution.
If you enjoy hunted meat, remember to chew a lot and cautiously while eating it. Do this so that the pleasure of eating hunted meat does not end in the operation room nor with lead poisoning.
Final note: Retained pellets/bullets are usually not removed because of the risk associated with the procedure. Common indications for bullets removal are:
bullets found in a joint
bullets in the cerebrospinal fluid
bullets inside the eye
bullets causing impingement on a nerve or a nerve root
bullets lying in a vessel lumen
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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