Foreign body ingestion is not unusual in the pediatric population. Treatment depends on the material ingested and can include immediate removal or expectant management. Review of Material Safety Data Sheets data is important. One area of concern is the ingestion of items containing lead, due to the uncorrectable effects of lead exposure. We present a case of ingested lead pellets in a child and review the initial evaluation and management of a retained pellet ultimately requiring single site appendectomy.
CASE PRESENTATION
A 3-year-old boy was seen in the pediatric Emergency Department after his mother reported his ingestion of gun pellets. The pellets were confirmed to contain lead after review of the Material Safety Data Sheets through a poison control center. An abdominal x-ray demonstrated 2 separate pellets within loops of intestine. His abdominal examination was benign. He was given an enema and discharged on MiraLAX with outpatient follow-up. Mom was instructed to screen his stools for passage of the pellets.
At follow-up 7 days later, 1 pellet was reported found in the stool. Repeat x-ray showed a retained pellet in the right lower quadrant. The patient's serum lead level was 27 μg/dL (normal 0–4 μg/dL) at his primary care physician and he was sent to the emergency department. The patient was admitted, and further cathartics were given with persistence of the pellet in the right lower quadrant on plain x-ray (Fig. 1 ). In addition, the child's home environment was screened for lead and found to be otherwise negative. Siblings were tested and found to have normal lead levels. Lead levels dropped to 14 μg/dL and the patient was discharged.
FIGURE 1: Abdominal x-ray of patient showing pellet in the right lower quadrant.
Consideration was given to the pellet being retained within the appendix. To delineate this, an abdominal ultrasound was obtained 22 days after ingestion. However, the resolution did not permit demonstration of the pellet within the appendix.
Subsequently, colonoscopy was performed 37 days after ingestion with excellent visualization of the right colon and cecum and the appendiceal orifice but no evidence of the pellet.
Repeat x-ray 6 weeks after ingestion showed no movement. Risks and benefits of surgical removal were discussed with the family due to the unlikelihood for the pellet to pass from the appendix. The child underwent laparoscopic exploration of the abdomen with extraction of the pellet 65 days after ingestion. Intraoperative fluoroscopy was used to aid in localization (Fig. 2 ). A single port was placed within the abdomen through the umbilicus. A grasper was inserted alongside the telescope and the appendix was brought into view. The pellet could be seen resting within the tip of the appendix confirmed by fluoroscopy. Simple appendectomy through the port site completed pellet removal. The child was discharged after brief observation and has done well at follow-up. The most recent lead level was down to 8 μg/dL (Fig. 3 ).
FIGURE 2: Fluoroscopic image with scope and grasper holding appendix.
FIGURE 3: Intraoperative image of patient's appendix with pellet lodged near the tip, arrow points to the pellet.
DISCUSSION
Ingestion of a foreign body is a common pediatric problem, although almost 95% of ingested foreign bodies pass through the alimentary tract (1) . Some foreign bodies mandate immediate removal, such as a coin battery in the esophagus or 2 or more magnetic toys. Ingested foreign bodies can become lodged by areas of anatomic narrowing such as the lower esophageal sphincter, the pylorus, and the ileocecal valve. At the ileocecal junction, foreign bodies can enter and become lodged within the appendix with an estimated incidence of 0.005% (2) . Objects which persist within the right lower quadrant should be removed by colonoscopy or if this fails, surgery due to the risk of perforation (3) . Although previous case reports have shown that over time, foreign objects within the appendix can pass spontaneously (4) in the case of our patient, 6 weeks had passed with little movement.
Lead poisoning is a serious disease that can affect adults and particularly children. The fear of lead ingestion has minimized with its reduction in household paints, but with the increasing prevalence of firearms, the fear of lead ingestion remains. According to the Centers for Disease Control (CDC), there is no safe blood lead level. The CDC recommends public health actions be initiated a child's lead levels become >5 μg/dL (5) . Lead poisoning can lead to neurologic and gastrointestinal symptoms such as seizure, death, anorexia, vomiting, and abdominal pain. Low lead levels can lead to adverse neurocognitive effects (6) . Laxative treatment is recommended in the presence of an intestinal opacity (7) . The CDC recommends chelation therapy when blood lead levels reach 45 μg/dL (8) .
Similar to our patient, lead toxicity from the ingestion of foreign bodies containing lead has been previously described (9–11) . Few cases have described the ingestion of lead containing ammunition. The case of a 15-year-old boy involved the inadvertent identification and removal of 3 rifle cartridges during endoscopic retrieval of a plastic fork (12) . The case of a 65-year-old woman involved purposeful ingestion of bullets resulting in endoscopic removal of 26 bullets (12) . In addition, a report of 3 pediatric patients showed a lead buckshot elimination with nasogastric polyethylene glycol solution, lead ball bearing ingestion elimination with magnesium citrate and enemas, and air gun pellet removal with colonoscopy (13) . One case report described a 15-year-old patient with a retained bullet within the appendix leading to an appendectomy 14 days after ingestion (14) . The patient was observed before symptoms of lead poisoning began and he was treated with chelation therapy. Most of the previous cases had far elevated lead levels requiring chelation for lead poisoning. Our case is unique because to our knowledge it is the only reported case of a bullet retained in the appendix of a small child leading to surgical treatment.
In the present case, serial radiographs showed stasis of bullet within the right lower quadrant suggesting the object was lodged within the appendix. The child was found to have an increased lead level which prompted expedited investigations and therapy, ultimately leading to surgical removal of the appendix. Physicians evaluating patients after ingestion of a metallic foreign body should investigate the composition of the foreign body and if lead is found or suspected, evaluate for the presence of elevated lead levels. Prompt nonoperative followed by operative measures to effect removal should follow.
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