Mutton Bone Ingestion Complicated by Terminal Ιleum Perforation


Dr D Gopal Rao, Dr K Suryanarayana, Dr T Srinivas, Dr K Raghu, Dr Satish, Dr R Naga S Ashok, Dr Yamuna, Dr Nyna Sindhu    06 January 2018


Mutton bone, ingestion, perforation, peritonitis

Enteric perforation and tubercular perforation  present the most common causes of terminal ileum perforation. Other causes are iatrogenic perforation, penetrating abdominal trauma and ingestion of foreign bodies. When animal bones, needles, toothpicks or other sharp pointed objects are ingested, the risk of perforation is even higher.

Mutton bone ingestion is a relatively rare event that may results in serious gut injuries with peritonitis, sepsis or even death.

Case presentation

We report the case of a 60-year-old man who was referred to our emergency department with a 2-day history of right lower abdominal pain, nausea, vomiting and low- grade fever. His vital signs were normal, except for a central body temperature of 38°C. There was no history of previous abdominal surgery. Physical examination revealed mild pain with positive rebound tenderness in the right lower abdominal quadrant and positive right costovertebral angle tenderness. There was no evidence of intra-abdominal masses. Routine blood tests were normal except for a WBC count of 11,860/mm3 with 84,6% neutrophils. On X-ray erect abdomen, pneumoperitoneum was seen (Fig. 1).

The patient underwent explorative laparotomy. At explorative laparotomy, a terminal ileal perforation due to mutton bone with localized peritonitis was found; resection and end-to-end anastomosis was performed. The patient made an uneventful recovery and was discharged on postoperative Day 7. The histological examination confirmed the presence of a transmural terminal ileum perforation with abscess caused by a mutton bone (Fig. 2).

Literature review

There are more than 300 cases1 of bowel perforation  caused by foreign bodies reported in the literature. Fish bones, chicken bones, mutton bones and dentures are the commonest objects followed by toothpicks and cocktail sticks.2-11 Male gender, mutton bone-crushing habit,  accompanied by alcoholic drinks were the main risk factors associated with mutton bone ingestion. Perforation of the ailmentary tract occurred in 80% of these patients; in one-third of them, the mutton bone had migrated into adjacent organs (liver, retroperitoneum, inferior vena cava, etc.). Figure 3 (a-d) depict the typical sites of mutton bone lodgement along the alimentary canal.


Mutton bone ingestion is a medical emergency, since it leads to acute abdomen and gut perforation. Since, spontaneous elimination of these sharp foreign bodies through the gastrointestinal tract is unlikely, foreign body ingestion should be taken into account during the evaluation of acute abdominal pain. The clinical presentation may include frank peritonitis, localized abscess formation, enterovesical fistula, intestinal obstruction and intestinal hemorrhage.1,9 The correct diagnosis is very difficult because of the low sensitivity of diagnostic investigations. Endoscopy can be very helpful when the mutton bone is localized in the upper  gastrointestinal  tract.5

The CT scan may be able to identify the site of perforation and the extent of intra-abdominal inflammation either with or without abscess formation. Although, the diagnostic yield is quite low, upper gastrointestinal endoscopy and ultrasound examination may be recommended in asymptomatic patients who are aware of the mutton bone ingestion and seek medical advice. The most common site of perforation is the terminal ileum and colon, although an increased incidence of perforation has been reported in association with Meckel’s diverticulum, the appendix and diverticular disease.12-16 Perforation commonly occurs at the point of acute angulation and narrowing.

Treatment usually involves resection of bowel, although occasionally repair has been described.1,13 X-ray abdomen showing pneumoperitoneum, considering the presence of an acute abdomen, with evidence of peritonitis, the patient was scheduled for surgical exploration and required resection and anastomosis.

This case suggests that a potential cause of lethal hazard may be unknown to the patient, but most of all it emphasizes the difficulty of a correct diagnosis with the most widely used instrumental examination, as endoscopy, ultrasound or CT scan. Consent to publish the case was obtained from our patient prior to discharge. The patient allowed us to share his story and clinical images because he understood the importance of raising awareness among physicians on this unusual surgical entity.


  1. Singh RP, Gardner JA. Perforation of the sigmoid colon by swallowed chicken bone: case reports and review of literature. Int Surg 1981;66(2):181-3.
  2. Ball JR. Complete perforation of appendix by a fish bone. Br J Clin Pract 1967;21(2):99.
  3. Bunch GH, Burnside AF, Brannon LJ. Intestinal perforation by ingested fish bone. Am J Surg 1942;55(1):169-72.
  4. Gunn A. Intestinal perforation due to swallowed fish or meat bone. Lancet 1966;1(7429):125-8.
  5. Perelman H. Toothpick perforations of the gastrointestinal tract. J Abdom Surg 1962;4:51-3.
  6. Dick ET. Cocktail stick perforation of the large bowel. N Z Med J 1966;65(412):986.
  7. Read KE. Intestinal perforation by wood splinter. Brit Med J 1946;1(4443):315.
  8. Lindsay R, White J, Mackle E. Cocktail stick injuries - the dangers of half a stick. Ulster Med J 2005;74(2):129-31.
  9. Li SF, Ender K. Toothpick injury mimicking renal colic: case report and systematic review. J Emerg Med 2002;23(1):35-8.
  10. Maleki M, Evans WE. Foreign-body perforation of the intestinal tract. Report of 12 cases and review of the literature. Arch Surg 1970;101(4):475-7.
  11. Sejdinaj I, Powers RC. Enterocolonic fistula from swallowed denture. JAMA 1973;225(8):994.
  12. McPherson RC, Karlan M, Williams RD. Foreign body perforation of the intestinal tract. Am J Surg 1957;94(4):564-6.
  13. McManus JE. Perforation of intestine by ingested foreign bodies: report of two cases and review of literature. Am J Surg 1941;53(3):393-402.
  14. Noh HM, Chew FS. Small-bowel perforation by a foreign body. AJR Am J Roentgenol 1998;171(4):1002.
  15. Maglinte DD, Taylor SD, Ng AC. Gastrointestinal perforation by chicken bones. Radiology 1979;130(3):597-9.
  16. Gregorie HB Jr, Herbert KH. Foreign body perforation of Meckel’s diverticulum. Am Surg 1967;33(3):231-3.

To comment on this article,
create a free account.

Sign Up to instantly get access to 10000+ Articles & 1000+ Cases

Already registered?

Login Now

Most Popular Articles

News and Updates

eMediNexus provides latest updates on medical news, medical case studies from India. In-depth medical case studies and research designed for doctors and healthcare professionals.