Case Presentation: A 56-year-old female with a history of scleroderma, Sjogren’s syndrome, GERD, cirrhosis, HTN presented with abdominal pain for 3 days. She reported nausea without emesis, decreased oral intake, and no bowel movements or passing gas during this time. She denied fevers, night sweats, diarrhea, gastrointestinal bleeding, recent travel, swimming in lakes/rivers, ingesting unclean water or undercooked food, sick contacts, having pets, and prior abdominal surgeries. She denied NSAID use but was taking losartan.She was tachycardic (118bpm) but otherwise vitally stable. Abdominal exam revealed diffuse tenderness on palpation and distension but without peritoneal signs. Labs revealed leukocytosis (WBC=16.3) and elevated CRP (335.5) and ESR (74). Liver chemistries were overall unremarkable. Lactate was increased (2.9) but lipase and TSH were normal. CT abdomen and pelvis was suggestive of enteritis with no bowel obstruction or perforation. Gastroenterology and Infectious Disease were consulted. Stool PCR revealed Enteropathogenic E.coli but other infectious workup was negative. Fecal calprotectin (83.7) and C4 (51) were not suggestive of IBD and hereditary angioedema, respectively. Push enteroscopy showed a normal duodenum and jejunum. Biopsies were negative for H.pylori, celiac disease, giardia, Whipple’s disease, and mycobacteria. Jejunal aspirates revealed SIBO but this was thought not to explain the enteritis prompting CT enterography (CTE). CTE was suggestive of sigmoid colon microperforation with a small adjacent abscess. On retrospective review of the previous CT by Radiology, there were small linear foreign bodies in the jejunum and sigmoid colon with the appearance consistent with grill brush bristles (GBB). Of this, on CTE, a single small linear fragment remained in the jejunum and the enteritis had resolved. Subsequently, the patient reported a history of ingesting grilled food 2 weeks before presentation and clarified that the abdominal pain started shortly after. Colorectal surgery recommended observation, antibiotics and repeat CT to ensure passing of the remaining GBB, which was confirmed. Her abdominal pain and intake improved, and she was discharged. At 6-week follow-up, imaging demonstrated resolution of the inflammation and fluid collection.
Discussion: Acute abdominal pain constitutes 5-10% of all ED visits where many patients are hospitalized for further evaluation and management. While abdominal pain has a broad differential, etiologies of enteritis can generally be divided into 4 major categories including infectious, inflammatory, autoimmune/immune-mediated and other (e.g. medications, radiation, ischemia), where the former is by far the most common. In our case, CTE revealed the enteritis to be due to sigmoid and possibly also jejunal perforation secondary to GBB ingestion. Grill brushes are utilized to clean grills, but bristles can break off, embed into food, and be accidentally ingested. While areas of involvement include the oropharynx, esophagus and small intestine, colonic perforation is quite rare in the literature. Depending on the clinical situation, management can be endoscopic, operative, or conservative.
Conclusions: Here we present a rare case of enteritis caused by sigmoid colon and possibly jejunal perforation. Foreign body ingestion should be in the differential for enteritis prompting further relevant history about recent ingestion of grilled foods and CTE if other workup is unremarkable.