Conservative management of elemental mercury retained in the appendix

Abstract

Introduction. Few cases of mercury sequestration in the appendix appear in the literature. Based on these, both prophylactic appendectomy and non-surgical management have been recommended. We report a case in which a patient with mercury retained in the appendix was managed conservatively without developing mercurialism or appendicitis. Case Report. A 43-year-old man ingested approximately one tablespoon of elemental mercury after an argument with his wife. An initial abdominal radiograph showed mercury in the pylorus of the stomach and a follow-up x-ray at 72 hours showed mercury localized to the appendix. The patient was treated as an outpatient and examined several times over a 37-day period. He never developed signs of appendicitis. On a follow-up examination 7 months after the ingestion, he was radiographically free of mercury. Periodically throughout his clinical course, blood mercury levels were obtained. Only one, 6 days after ingestion, showed an elevated mercury level of 68 mcg/L (reference range <10 mcg/L). Despite this, the patient never developed signs or symptoms of mercury poisoning. Conclusion. Patients in whom elemental mercury is retained in the appendix, who are without symptoms and have normal gastric mucosa, may be conservatively managed without surgery.

Heavy metal poisoning: management of intoxication and antidotes

“…Inhaled vapor is largely eliminated in the urine with an elimination half-life of about 60 days [49]. Compared to the respiratory tract, GI absorption is negligible [50] and represents little risk for patients with intact GI mucosa [51]. Toxicity can occur if the GI mucosa is not intact [52].…”

Assessment and management of elemental mercury poisoning—a case report

“…As mentioned above, appendicitis is a possible complication of sequestration of ingested mercury in the appendix . Although prophylactic appendectomy is proposed as an invasive approach , there are reports that conservative approach can be efficient and safe for the patient . Additionally, we believe that appendectomy of an appendix filled with mercury may not be safe because of the possible effusion of the mercury in the peritoneal cavity and the subsequent systemic toxicity, although similar reports have not published.…”

“…Furthermore, in some clinical conditions in which mercury remains for prolong periods in the GI tract, such as diverticulosis, there is a possibility of conversion of elemental mercury to organic by bacteria leading with that way to systemic toxicosis . Gastrointestinal complications after mercury ingestion such as granulomas and abscesses have also been reported . As mentioned above, appendicitis is a possible complication of sequestration of ingested mercury in the appendix .…”

“…In most cases, elemental mercury is excreted with feces within few days. However, cases in which elemental mercury has been retained in the appendix have been described . Furthermore, cases of appendicitis after mercury ingestion have also been reported so prophylactic appendectomy has been proposed .…”

Laparoscopic appendectomy for elemental mercury sequestration in the appendix: A case report

“…Besides irrigation methods, the Trendelenburg position (30°) combined with left lateral decubitus position has also been reported to be successful in one patient[12]; although this approach failed to remove the mercury from the appendix in other patients[3]. Moreover, one report also described a complete spontaneous elimination of appendiceal mercury within 7 mo without any associated complication[13]. We believe that the effectiveness of the conservative methods may be significantly influenced by the variations in the anatomy and location of the appendix.…”