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Ultrasound Diagnosis of Crystal Jelly Ball Ingestion Causing Intestinal Obstruction

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Ingestion of Foreign Bodies (FB) by young children is a common presentation in the emergency department. We present two cases which were diagnosed with intestinal obstruction. Abdominal ultrasound revealed an intraluminal anechoic cystic lesion causing intestinal obstruction in both cases. We discuss the ultrasound findings of an intraluminal crystal jelly ball FB highlighting the technical consideration on ultrasound probe selection. In both cases, Intraoperative findings confirmed that the small bowel obstruction was due to a crystal jelly ball bezoar. Keywords: Ultrasound; Jelly ball; Intestinal obstruction
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Citation: Faizah MZ, Soon YY, Che Zubaidah CD, Mohd Yusof A and Dayang AA. Ultrasound Diagnosis of
Crystal Jelly Ball Ingestion Causing Intestinal Obstruction. Austin J Radiol. 2016; 3(2): 1046.
Austin J Radiol - Volume 3 Issue 2 - 2016
ISSN : 2473-0637 | www.austinpublishinggroup.com
Faizah et al. © All rights are reserved
Austin Journal of Radiology
Open Access
Abstract
Ingestion of Foreign Bodies (FB) by young children is a common
presentation in the emergency department. We present two cases which
were diagnosed with intestinal obstruction. Abdominal ultrasound revealed
an intraluminal anechoic cystic lesion causing intestinal obstruction in both
cases. We discuss the ultrasound ndings of an intraluminal crystal jelly ball FB
highlighting the technical consideration on ultrasound probe selection. In both
cases, Intraoperative ndings conrmed that the small bowel obstruction was
due to a crystal jelly ball bezoar.
Keywords: Ultrasound; Jelly ball; Intestinal obstruction
Introduction
Foreign Body (FB) ingestion can cause serious morbidity and
mortality, especially among children aged six months to three years
[1,2]. Unfortunately, almost half of these cases are not witnessed
and oen the child does not develop symptoms until presented with
complications [3]. ere is very little discussion in the literature
regarding ultrasound appearance of a radiolucent intraluminal FB
such as a crystal jelly ball. Previous literature did not describe the
ultrasound ndings but the radiograph and CT ndings instead of this
unique FB ingestion [4]. We aim to present a case series of crystal jelly
ball ingestion emphasizing on the ultrasound ndings. Ultrasound is
a preferred imaging modality in children as it is readily available and
no radiation involved. ere was no history of FB ingestion prior to
the pre-operative ultrasound in both cases.
Case Series
Case 1
An 18 month old girl presented with a history of two days of
vomiting with poor oral intake. ere was no associated fever or
diarrhoea. Upon examination, she was dehydrated and lethargic.
Her abdomen was still so, non-tender and not distended. She was
admitted and treated for acute gastroenteritis. e following day, she
developed bilious vomiting.
Abdominal ultrasound using a L12-5 MHz supercial probe
Philips IU22 ultrasound (Eindhoven, e Netherlands) demonstrated
a well-dened anechoic thin-walled, intraluminal cystic lesion. e
lesion was suspected to be in the splenic exure as it was located at
le hypochondrium with presence of dilated right sided colon. e
provisional diagnosis was an enteric duplication cyst since there was
a “double wall sign” noted (Figure 1).
A lower gastrointestinal study was performed due to the suspicion
of an intracolonic lesion. e results showed opacication of the
Case Series
Ultrasound Diagnosis of Crystal Jelly Ball Ingestion
Causing Intestinal Obstruction
Faizah MZ1*, Soon YY1, Che Zubaidah CD2, Mohd
Yusof A3 and Dayang AA4
1Department of Radiology, Universiti Kebangsaan
Malaysia Medical Center, Malaysia
2Department of Diagnostic Imaging, General Hospital of
Kuala Lumpur, Malaysia
3Department of Pediatric Surgery, General Hospital of
Kuala Lumpur, Malaysia
4Department of Surgery, Universiti Kebangsaan Malaysia
Medical Center, Malaysia
*Corresponding author: Faizah MZ, Department
of Radiology, Universiti Kebangsaan Malaysia Medical
Center, Jalan Yaacob Latiff, 56000 Cheras, Kuala
Lumpur, Malaysia
Received: January 18, 2016; Accepted: February 23,
2016; Published: February 24, 2016
descending colon up to the splenic exure with sudden tapering.
However, since there was no evidence of “claw sign” to suggest
intussusception with no describable features on earlier ultrasound,
the impression was that the intraluminal cystic lesion was in the small
bowel and has caused compression to the adjacent splenic exure.
An emergency diagnostic laparotomy and enterotomy was
performed soon aer the imaging study and revealed a mobile
intraluminal mass in the jejunum which was a crystal jelly ball bezoar.
Aer an operation to remove the bezoar, the child recovered well and
was discharged aer three days.
Case 2
A previously healthy 17 month old girl, presented to emergency
room with non-bilious vomiting for one day and poor oral intake.
ere was no documented history of foreign body ingestion. Later,
Figure 1: Eighteen-month-old girl with crystal jelly ball ingestion (Case 1).
The transabdominal transverse sonogram using linear supercial probe L12-
5 MHz demonstrates an intraluminal anechoic cystic lesion with a “double
wall sign” of thin hyperechoic inner layer (white arrow) and thin hypoechoic
outer layer (black arrow).
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she developed abdominal distension and nil bowel output for 3 days.
Examination revealed that she was febrile and dehydrated with a
distended abdomen.
She was then referred to the paediatric surgery team with
provisional diagnosis of intestinal obstruction. An abdominal x-ray
showed evidence of intestinal obstruction with no radio-opaque
intra-abdominal lesion. Ultrasound evaluation of the abdomen using
a C8-5 MHz convex probe Philips ATL ultrasound (Eindhoven, e
Netherlands), showed a well-dened hypo echoic intraluminal lesion
at the distal ileum which was mobile with peristalsis. ere were
dilated small bowel loops proximal to this lesion. Primary diagnosis
of a foreign body was suspected (Figure 2).
e patient underwent laparotomy and enterotomy.
Intraoperative ndings showed a bezoar comprised of a jelly-like
material fragmented into multiple pieces within the ileum (Figure 3).
Post-operatively, the child recovered well and was discharged aer
ve days.
Discussion
As a natural way to explore their curiosity and begin to learn
about the world around them, young children oen place various
items into their mouths. Although this is normal developmental
behaviour, it can also create a dangerous scenario. Ten-twenty percent
of ingested Foreign Bodies (FB) into the gastrointestinal system
requires endoscopic removal, and less than 1% require surgery when
complicated by intestinal obstruction, stricture, or even perforation
[1-3].
e most common ingested FB in children is organic with
approximately more than half of the cases are peanut [2]. Organic
materials are radiolucent on radiograph and this is also true
in decorative crystal jelly balls. Radiograph will only show the
complications of intestinal obstruction which is similar as in our
cases [4]. On the other hand, radiopaque FB such as coins, batteries,
sharp or metal objects, magnets, bone particles and fruit stones were
demonstrated in 26.55% of cases [1,3].
Crystal jelly balls, oen used for planting or decorative purposes,
are attractive to children because of their interesting color and
texture. Made from a polymer which can act as water reservoir, they
can absorb water 100 times more than their dry volume and expand
30-60 times their original volume [5]. us, if ingested, a crystal
jelly ball can cause intestinal obstruction especially proximal to the
ileocecal junction [4,6].
To our current literature review, there is no reported case
discussion pertaining to the sonographic appearance of an
intraluminal crystal jelly ball. Previous literature described that
this FB demonstrated as an intraluminal hypodense mass on CT
and sign of intestinal obstruction [4]. Our case series showed that
an intraluminal crystal jelly ball could mimic other sonographic
ndings, such as an enteric duplication cyst. On sonography, enteric
duplication cyst shows an inner hyperechoic mucosal rim and outer
hypo echoic muscular rim giving rise to a “double wall sign” or “gut
signature sign” [7]. However, there are other lesions that can mimic
these signs which are commonly described as “pseudo double wall”
signs or “pseudo gut signature” signs; examples being a mesenteric
cyst or twisted ovarian cyst [8].
e intraluminal crystal jelly ball in case 1 was demonstrated as
a well-dened anechoic lesion with “double-wall sign”, using a high
frequency probe (12MHz). In comparison, the intraluminal crystal
jelly ball in Case 2 did not show the “double wall sign” when a lower
frequency probe was used (8MHz). is interface phenomenon
artifact may be observed along the wall of other cysts and may mimic
the “double wall sign” conguration in duplication cysts. A previous
study stated that this artifact presented in 12 of 27 non-enteric cysts
which was seen over a small segment of the lower portion of the
cyst wall and disappeared with slight movements of the transducer.
A false-positive sign may become a more frequent occurrence with
higher-frequency ultrasound probes [7].
We had six additional similar cases in our country that were
correctly diagnosed as an intraluminal crystal jelly ball upon
preoperative ultrasound. We alerted our Ministry of Domestic
Figure 2: Seventeen-month-old girl with crystal jelly ball ingestion (Case 2).
The transabdominal transverse sonogram using curvilinear probe C8-5 MHz
shows a well-dened anechoic lesion with a thin hyperechoic wall (arrows)
within the small bowel. The visualized proximal small bowel is dilated and
uid-lled.
Figure 3: Seventeen-month-old girl with crystal jelly ball ingestion (Case 2).
Specimen of a polymer crystal jelly ball bezoar obtained post-operatively after
removal following enterostomy.
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Trade, Co-operatives and Consumerism regarding the medical
complications of this household product, which resulted in an ocial
ban of the crystal jelly ball in our country [9].
In conclusion, intraluminal crystal jelly ball FB can be devastating
as it can result in intestinal obstruction due to its absorptive eect. It
is radiolucent on radiograph and hypodense on CT when located in
the intestinal lumen. Whereas, the FB appeared as an anechoic cystic
mass on ultrasound that sometimes may mimic an enteric duplication
cyst. is criteria is crucial in order to avoid unnecessary additional
imaging, especially when radiation protection is of major concern in
paediatric population.
References
1. Sahin A, Meteroglu F, Eren S, Celik Y. Inhalation of foreign bodies in children:
experience of 22 years. J Trauma Acute Care Surg. 2013; 74: 658-663.
2. Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese children: a review
of 400 cases. Laryngoscope. 1991; 101: 657-660.
3. Chung S, Forte V, Campisi P. A review of pediatric foreign body ingestion and
management. Clinical Pediatric Emergency Medicine. 2010; 11: 225-230.
4. Mirza B, Sheikh A. Mortality in a case of crystal gel ball ingestion: an alert for
parents. APSP J Case Rep. 2012; 3: 6.
5. Decorative water crystal™ website.
6. Mirza B, Ijaz L, Sheikh A. Decorative crystal balls causing intestinal
perforation. J Indian Assoc Pediatr Surg. 2011; 16: 106-107.
7. Cheng G, Soboleski D, Daneman A, Poenaru D, Hurlbut D. Sonographic
pitfalls in the diagnosis of enteric duplication cysts. AJR Am J Roentgenol.
2005; 184: 521-525.
8. Godfrey H, Abernethy L, Boothroyd A. Torsion of an ovarian cyst mimicking
enteric duplication cyst on transabdominal ultrasound: two cases. Pediatr
Radiol. 1998; 28: 171-173.
9. ‘Crystal ball’ seed-growing kits banned from The Star Online website. 2011.
Citation: Faizah MZ, Soon YY, Che Zubaidah CD, Mohd Yusof A and Dayang AA. Ultrasound Diagnosis of
Crystal Jelly Ball Ingestion Causing Intestinal Obstruction. Austin J Radiol. 2016; 3(2): 1046.
Austin J Radiol - Volume 3 Issue 2 - 2016
ISSN : 2473-0637 | www.austinpublishinggroup.com
Faizah et al. © All rights are reserved
... After reading the full texts or abstracts, we removed reports reporting ear canal obstructions (N ¼ 2), ingestions without bowel obstruction (N ¼ 14), and bowel obstructions not related to the ingestion of superabsorbent polymer-made products (N ¼ 67). Overall, 25 reports reporting 43 cases were considered for analysis: 20 articles with English full-text [3,10,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31], three articles with English abstracts but not English full-texts (two in Russian and one in Korean) [32][33][34], and two conference abstracts (one in English and one in French) [5,35]. The first report was published in 2011 [22]. ...
... The first report was published in 2011 [22]. All the included reports were retrospective, including 20 case reports [3,10,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][32][33][34][35] and 4 case series [5,[14][15][16]31]. ...
... Age was available in all reports, except for one case series of 15 patients which provided only the mean age and age range [31] (Table 1). In the reports providing age individually, the median age was 15 months (interquartile range: [10;18]) [3,5,10,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][32][33][34][35]. In the case series, the mean age was 2 years [31]. ...
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Rationale Superabsorbent polymers are marketed as toys, and cases of ingestion in children are increasingly reported. Even if these cases are usually considered benign, bowel obstruction has been reported. Objective To investigate the exposure characteristics, clinical presentation, management, and outcome of patients who developed bowel obstruction following ingestion of superabsorbent polymer-made products. Methods Databases were searched (no start date − 2020/01/31) using the following keywords: (“superabsorbent” OR "polymer” OR “hydrogel” OR “crystal” OR "jelly" OR “Orbeez” OR "beads") AND (“ingestion” OR “obstruction” OR "perforation") AND (“intestinal” OR “bowel”). All cases of bowel obstruction following superabsorbent polymer-made product ingestion were included. Results Report selection: We found 25 reports reporting 43 cases of bowel obstruction following superabsorbent polymer-made product ingestion. All the reports were retrospective, including 20 case reports and 4 case series. Patient characteristics and clinical presentation: Age ranged from 6 to 36 months, and the female/male sex ratio was 1.3. The median delay between the ingestion of the product and the onset of the first symptoms (available in only four reports) was 1.0 [0.7;1.8] day (from 15 h to 2 days). The median delay between the onset of gastrointestinal symptoms and hospital admission, available for all but 15 patients, was 3 [2;4] days (from 15 h to 30 days). The reported symptoms were persistent vomiting in all cases, associated with constipation (11/43), diarrhea (1/43), abdominal pain (1/43), and clinically assessed dehydration (14/43). Abdominal palpation found abdominal tenderness or distension in 11/43 and 28/43 patients, respectively. An abdominal mass was palpated in 3/43 patients. Two patients presented with fever, and three patients developed seizures. Characteristics of exposure: Ingestion of superabsorbent polymer-made products was reported by relatives on hospital admission in only 10/43 cases. Based on imaging and/or surgically/endoscopically removed products, all were bead-shaped objects. The median number of beads removed (available in 27/43) was 1 [1–2] (range from 1 to 6). Their median diameter (available in 21/43 patients) at the time of the diagnosis of bowel obstruction – i.e., at hydrated state – was 30 [30;36] mm (range from 25 to 65 mm). Imaging findings: Abdominal radiography, performed in 31/43 patients, never showed evidence of foreign body ingestion Abdominal computed tomography scanning, performed in 10/43 patients, visualized an intraluminal mass in 5/10 cases. Abdominal ultrasound performed in 34/43 patients allowed visualization of a rounded intraluminal image that corresponded to a bead in 28/34 patients but led to a correct diagnosis of foreign body-induced bowel obstruction in only 15/34 cases. One case reported the contributory use of abdominal MRI. Beads were always located in the small bowel (from the duodenum to the terminal ileum). Removal of beads: Bead removal required endoscopy in 2/43 cases and surgery in 41/43 cases (enterotomy or resection in 36/43 and 5/43 cases, respectively). In 3/36 cases, additional enterotomy was performed to remove beads that had not been found during the first surgery. The delay between the onset of gastrointestinal symptoms and removal procedures ranged from 1 to 7 days. Outcome: Except for two fatal cases, the outcome was favorable. Conclusions Ingestion of superabsorbent polymer-made beads can be responsible for fatal bowel obstruction in children related to the increase in bead size within the intestinal tract. Diagnosis is made difficult by the radiolucent properties of the beads. The management of bowel obstruction probably most often requires endoscopic or surgical procedures. Children under 4 years of age are probably the most at risk of developing bowel obstruction.
... It may result in intestinal perforation and peritonitis. [1][2][3] In our case it caused partial duodenal obstruction for a month. ...
... Faizah et al showed that an intraluminal crystal jelly ball could mimic other sonographic pathologies, such as an enteric duplication cyst. [3] In our case crystal gel ball had occupied duodenum and its hypoechoic shadow on USG and hypodense nature on CT scan simulated a cystic structure in relation to duodenum thus mimicked as duplication cyst. Community awareness is mandatory to stop using such material in homes as a case of mortality secondary to ingestion of crystal gel ball ingestion has been reported in literature. ...
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Paediatric age group is most vulnerable for the accidental foreign body (FB) ingestion which may go unnoticed. These patients present with symptoms or complications as a result of FB and may mimic other conditions on various investigations. We describe a 9-month old infant who ingested crystal gel ball and presented with vomiting for a month. On radiological imaging, it was interpreted as duplication cyst of the duodenum. At operation, crystal gel ball was retrieved. Our case vindicates importance of keeping various possibilities in mind as differential diagnoses during evaluation and management of surgical ailments such as the duplication cyst of duode-num.
... 8 In contrast, USG is helpful to identify these FB showing cystic lesion with double wall sign, a crucial sign to avoid unnecessary additional imaging and harmful radiation in children. 4,9 All children in our study presented with features of GIT obstruction due to ingestion of SAPGBs underwent Lap-MIS. However, asymptomatic stable children, with normal laboratory, X-ray, and ultrasound findings can be managed without surgery as reported in a retrospective chart analysis of 21 children during a 10-year period, 6 were hospitalized and 15 observed as outpatients. ...
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... One case report has mentioned the "double wall sign" or "gut signature sign" in intestinal obstruction with jelly balls. But, other lesions can also present in a similar way in radio imaging (8). ...
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Citation: Faizah MZ, Soon YY, Che Zubaidah CD, Mohd Yusof A and Dayang AA. Ultrasound Diagnosis of Crystal Jelly Ball Ingestion Causing Intestinal Obstruction
'Crystal ball' seed-growing kits banned from The Star Online website. 2011. Citation: Faizah MZ, Soon YY, Che Zubaidah CD, Mohd Yusof A and Dayang AA. Ultrasound Diagnosis of Crystal Jelly Ball Ingestion Causing Intestinal Obstruction. Austin J Radiol. 2016; 3(2): 1046.