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foreign body consumption. As symptoms begin to arise in the patient, it is important for the physician and patient to have a clear timeline in terms of these symptoms. Providing a timeline can help aid the medical team/physician in being able to
determine if investigation in the matters of a potential foreign body would be
deemed necessary. A major issue when considering a diagnosis of foreign body
ingestion is the variety of symptoms that can change solely based on the location of
the foreign body along the digestive tract. There have been instances where ingestion has been mistaken for other bowel disorders like Crohn’s disease [2]. Even
though symptoms can be characterized as several different disorders, it is imperative to the prognosis of the patient that a correct diagnosis is made. That is the case
with the following case presentation listed in this report. Even though this report
highlights one specic case of misdiagnosis in conjunction with a foreign body
ingestion, this scenario is not rare. This case also highlights the personal consequences for the patient when it comes to a misdiagnosis when dealing with a foreign body ingestion. The case is meant to highlight this potential issue in medicine
and help refresh the possibility of a foreign body ingestion when dealing with
abdominal complaint patients.
Clinical Case Presentation
A 56-year-old Greek Caucasian woman presented to a primary care setting, in rural
Crete, Greece, complaining of mild lower abdominal pain, cramping, and bloating,
during the last 4 months. The pain was located primarily in the left upper quadrant
and often affected the entire abdomen. Her symptoms gradually worsened over
time, with only temporary relief with defecation. She reported that her bowel habits
changed approximately 1 month after the onset of her abdominal symptoms.
Alternating constipation and diarrhea was reported, with diarrhea being more predominant. She also reported a sensation of incomplete bowel emptying. A change in
the frequency of bowel movements was also reported. She denied any bleeding,
29 Foreign Body Ingestion Misdiagnosed asIrritable Bowel Syndrome
197
fever, or weight loss. She also denied having any aggravating symptoms such as
stress and certain foods over the last few months. Complete physical examination
was within normal limits. Vital signs were also within normal limits. Our patient’s
medical history included hypertension (treated with an angiotensin II receptor
antagonist, telmisartan), hypothyroidism (treated with L-thyroxine), and hypercholesterolemia (treated with atorvastatin), as well as some other minor bowel and gastric disorders that were chronic. There were no concerning associated signs or
symptoms such as anemia or weight loss that would have led the family physician
to initiate further studies. No abdominal or other surgical operations were reported.
The family history for colorectal cancer was negative. The rst impression was that
the patient had IBS.General dietary advice according to the National Institute for
Health and Clinical Excellence (NICE) guidelines for primary care management of
IBS was given (regular meals, avoiding long gaps between eating, adequate and
appropriate uid intake). The patient also received mebeverine hydrochloride
135mg three times daily for 3 weeks. The diagnostic approach included laboratory
tests and an abdominal ultrasound control. Laboratory tests results revealed a normal complete blood count, normal erythrocyte sedimentation rate and C-reactive
protein, and normal stool studies. Abdominal ultrasound revealed that her gallbladder, biliary tree, pancreas, spleen, and right kidney were all within normal limits.
The lower portion of the left kidney was difcult to visualize secondary to the presence of a loop of bowel. Because her symptoms persisted despite treatment, a colonoscopy was ordered. The colonoscopy revealed the following: rectum with
rst-degree hemorrhoids, sigmoid and descending colon with increased spasticity
and normal mucosa, and a normal ileum. In the ascending colon, a sharp piece of a
birthday cake decoration was found and removed (Fig.29.1). No necrosis of bowel
mucosa or hemorrhage was observed. The increased bowel spasticity that was
observed was interpreted by the gastroenterologist who performed the colonoscopy
as possible IBS resulting as a consequence of the foreign body irritation (Fig.29.2).
The dimension of the foreign body is shown in comparison with a key in Fig.29.3.
One week after the removal of the foreign body, all symptoms resolved. Our patient
was free of symptoms after 8 months of follow-up [3].
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A. K. Shetty and D. Soria
Fig. 29.1 Colonoscopy images showing the foreign body [3]
29 Foreign Body Ingestion Misdiagnosed asIrritable Bowel Syndrome
199
Fig. 29.2 Colonoscopy images showing increased bowel spasticity [3]
200
Fig. 29.3 Dimension of the foreign body in comparison with a key [3]
A. K. Shetty and D. Soria
Differential Diagnosis
1. Irritable Bowel Syndrome (IBS)—The patient presentation as described earlier
would lean heavily toward irritable bowel syndrome without the knowledge of
the patient having ingested a foreign body. Irritable bowel syndrome is characterized as having symptoms such as abdominal pain and altered bowel habits
(diarrhea and/or constipation) as seen in this patient. In addition to this, the
patient was noted for meeting the Rome III criteria for IBS [4].
2. Inammatory Bowel Disease (IBD)—Subsequently, once again going back to
the patient presentation and history, given the alternating constipation and diarrhea, inammatory bowel disease was another differential. The patient’s gastrointestinal issues outside of the defecation also included abdominal pain which is
a feature of IBD.
3. Foreign Body Ingestion—The patient presented with mild lower abdominal
pain, cramping, and bloating, during the last 4 months. With pain located primarily in the left upper quadrant, affecting the entire abdomen at times. With relief
only coming, temporarily, at times of defecation. The symptoms also were stated
that she encountered alternating constipation and diarrhea. Due to denial of
bleeding and not noticing that she had ingested foreign material, this was ultimately not considered until later. It wasn’t until the recurrence of these symptoms after initial treatment for irritable bowel syndrome did the team go for
further investigation. In a study, it was found that foreign bodies are encountered
at endoscopy in almost half of the cases. Foreign body ingestion and food impaction are one of the most frequent emergencies in gastroenterology/exible
endoscopy [5].
29 Foreign Body Ingestion Misdiagnosed asIrritable Bowel Syndrome
201
What WasMisdiagnosed inThis Case andWhy?
Foreign body ingestion was misdiagnosed as irritable bowel syndrome in this
patient. Given the immediate symptoms present at time of admission and subsequent medical history and a complete physical examination within normal limits,
the physicians honed in on diseases that manifested alternating diarrhea and constipation. In viewing this patient and utilizing Rome III diagnostic criteria for IBS
being symptoms lasting at least 3 months, preceded by at least 6 months of recurrent
abdominal pain or discomfort associated with two or more of the following;
improvement with defecation, onset associated with change in frequency of stool,
or; onset associated with a change in form of stool [4, 5]. The physicians on hand
noticed that their patient met the criteria laid out in the Rome III guidelines, and
given that NICE guidelines for management of IBS does not indicate ultrasound or
colonoscopy, there would normally not be a follow-up in terms of investigative
nature. It was due to the team pushing for a colonoscopy after treatment did not
affect the symptoms that the foreign body was found. In addition to this, it should
be noted that the patient herself did not realize she had ingested a foreign body,
which led to a signicant delay.
Discussion
In order for a medical team to reach the diagnosis of foreign body ingestion, there
are certain considerations that need to be taken by the team. While foreign body
ingestion remains a common clinical issue, there are various techniques that will
help elucidate a better understanding of the natural history of foreign body ingestion
[1]. While it is entirely possible that the patient does not remember ingesting foreign
material, it is the responsibility of the presiding medical team to fully explore the
medical history in an attempt to uncover an ingestion. When the patient does not
remember that they have ingested something out of the norm, this should not immediately rule out the possibility by the medical team. There should always be an
individualized approach to patient care. While suspicion may vary, the most direct
way to conrm the suspicion of foreign body ingestion is via investigative measures, be it computerized tomography (CT), endoscopy, or colonoscopy. In the case
described in this report, these investigative measures did not occur until the preliminary diagnosis of IBS was made and treatment did not alleviate the symptoms. The
medical team in this report utilized the Rome III criteria for functional GI disorders.
Rome III criteria is an aid to help distinguish between functional GI disorders and
offers a basic framework for physicians to work within in order to help make accurate and specic diagnosis for those suffering from GI issues. As described in the
report, the patient was not aware of the consumption of foreign material, which led
the medical team to a diagnosis that did not involve foreign body ingestion. Through
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A. K. Shetty and D. Soria
the use of the Rome III criteria, they were able to suspect the patient was suffering
from irritable bowel syndrome. The criteria outlined in the Rome III that led them
to this diagnosis involved improvement with defecation, onset associated with a
change in frequency of stool, or onset related to a change in form (appearance) or
stool [4]. Using the framework provided, they deduced that the patient at hand had
met all of the criteria and thus the diagnosis was made in favor of irritable bowel
syndrome. As described previously the patient did not have any alleviation of their
symptoms after initial treatment which prompted the usage of ultrasound that
revealed the obscurity of the left kidney due to the presence of a loop of bowel. With
the persistence of the symptoms, this also prompted a colonoscopy to be ordered.
The case report details the results of that colonoscopy which ultimately led to the
removal of the foreign body, which was described as a birthday cake decoration.
With the passage of this foreign body into the ascending colon where it was then
lodged, this proves to be a deviation from the norm of most foreign body ingestions.
In most patients with foreign bodies, they are passed simultaneously (n − 410,
75.6%) without complication, and only 4.87% (n−76) required surgery for removal
of the foreign material [6]. Impaction of a foreign body in the location of the colon
is not a common occurrence, as most foreign bodies are either passed or are found
in the upper gastrointestinal tract [7]. Due to the unusual nature of the foreign body
as present in the patient described in the case, it helps others understand the thinking
process of the presiding medical team. The patient could be seen as more of an irritable bowel patient as opposed to a foreign body suspicion. If not for the failure of
the alleviation of the symptoms, it is entirely possible that the foreign body could
have manifested other complications in the long run.
Plan ofAction
1. When a patient is admitted for abdominal complaints, the presiding physician
should obtain a detailed medical history. With an emphasis on normal eating
behavior, ask about changes to diet as well as the possibility of eating something
that could be considered foreign.
2. The presiding physician should be up to date with physical examination practices in consideration of abdominal complaints. Even if the medical history
seems trivial, a proper workup should be executed
3. The suspicion of a foreign body should be elevated unless proven otherwise via
further investigation.
4. Analyze the variety of diagnostic tools, and accurately determine what investigative method could rule in or rule out foreign body ingestion or other bowel
related disorders.
5. In the event a diagnosis, not in line with foreign body ingestion, is made, take
into account the possibility of a foreign body being present at time of follow-up
visit with intention to review any changes in symptoms after initial treatment.
29 Foreign Body Ingestion Misdiagnosed asIrritable Bowel Syndrome
203
Conclusion
With IBS-like symptoms that were an unusual manifestation due to a foreign body,
there would need to be an increase in suspicion from the primary care physicians
when dealing in the treatment and diagnosis of abdominal complaints.
References
1. Selivanov V, Sheldon GF, Cello JP, Crass RA. Management of foreign body ingestion. Ann
Surg. 1984;199(2):187–91. https://doi.org/10.1097/00000658- 198402000- 00010.
2. O’Gorman MA, Boyer RS, Jackson WD.Toothpick foreign body perforation and migration
mimicking Crohn’s disease in a child. J Pediatr Gastroenterol Nutr. 1996;23(5):628–30. https://
doi.org/10.1097/00005176- 199612000- 00021.
3. Komninos ID, Tsiligianni IG.Foreign body ingestion mimicking irritable bowel syndrome: a
case report. J Med Case Rep. 2010;4:244. https://doi.org/10.1186/1752- 1947- 4- 244.
4. http://www.romecriteria.org/pdfs/RomeCritieraLaunch.pdf
5. Libânio D, Garrido M, Jácome F, Dinis-Ribeiro M, Pedroto I, Marcos-Pinto R. Foreign
body ingestion and food impaction in adults: better to scope than to wait. United European
Gastroenterol J. 2018;6(7):974–80. https://doi.org/10.1177/2050640618765804.
6. Velitchkov N, Grigorov G, Losanoff J, etal. Ingested foreign bodies of the gastrointestinal tract:
retrospective analysis of 542 cases. World J Surg. 1996;20:1001–5. https://doi.org/10.1007/
s002689900152.
7. Khorana J, Tantivit Y, Phiuphong C, Pattapong S, Siripan S.Foreign body ingestion in pedi-
atrics: distribution, management and complications. Medicina (Kaunas). 2019;55(10):686.
https://doi.org/10.3390/medicina55100686.
Part VI
Gynecology
Chapter 30
Hydatidiform Mole Misdiagnosed
asaThreatened Abortion
PushpaBhatt andRevathiMyneni
Learning Objectives
By the end of this presentation, the clinician will be able to:
1. Dene the HM pregnancy with differential diagnosis in a patient presenting with
symptoms of vaginal bleeding suspecting for vesicular mole with complete history with physical examination of the patient.
2. Evaluate the medical history and complete physical examination to exclude
other clinical conditions and most appropriate course of investigation needed to
a denitive diagnosis of HM.
3. Discuss the consequences of misdiagnosis of HM.
4. Apply if a hydatidiform mole is suspected on clinical grounds, ultrasonic scanning, and quantitative estimation of serum ẞ-HCG should be carried out to conrm the diagnosis.
5. Diagnose and treat HM will probably result in the decrease of complications
with positive outcome as found in this study.
Introduction
A hydatidiform mole is also known as molar pregnancy. It is a rare complication of
pregnancy characterized by the abnormal growth of trophoblasts, the cells that normally develop into the placenta. Due to the distinctive gross appearance, hydatidiform moles (molar pregnancies) have been described since ages. Hydatidiform mole
(HM) was rst described by Hippocrates around 400 BCE as “dropsy of the uterus”
[1]. Molar pregnancy is common in Southeast Asia, African countries, and Central
P. Bhatt (*) · R. Myneni
St. Martinus University Faculty of Medicine, Willemstad, Curacao
e-mail: pushpa.bhatt@martinus.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Tohid et al. (eds.), The Misdiagnosis Casebook in Clinical Medicine,
https://doi.org/10.1007/978-3-031-28296-6_30
207