Small bowel perforation caused by an ingested foreign body masquerading as acute appendicitis

Aman aged 45 years presented with a 9-hour history of lower abdominal pain, which was worse in the right iliac fossa. The pain was sharp in nature and worse with movement. There was no nausea or vomiting. He had previously been well and healthy. On admission, he was apyrexial (37.0°C), had a normal pulse rate (75 beats/min) and was normotensive (120/80 mmHg). Clinical examination was significant for right iliac fossa tenderness but there was no guarding or rebound. There was no blood on urinalysis. His blood tests revealed a raised white cell count (12.4×109/litre), a normal neutrophil count (7.40×109/litre), a raised C-reactive protein (122 mg/litre) and a normal serum amylase (33 U/litre). Erect chest X-ray and plain abdominal X-ray were normal. On re-examination, his pain had worsened and he had increasing peritonism in his right iliac fossa, so he was listed for an urgent appendicectomy.