Intentional Foreign Body Ingestion in Adults: A Novel Case of Ingestion of a 13.6 cm Metallic Shank by a Prisoner for Secondary Gain That had to Be Surgically Removed 1912

• Published in: The American journal of gastroenterology Vol. 113; no. Supplement; pp. S1085 - S1086
• Main Authors: Abbas, Syed H., Nawaz, Waqas, Hertan, Hilary
• Format: Journal Article
• Language: English
• Published: New York Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins 01.10.2018
• Subjects: Abdomen; Esophagus; Foreign bodies; Gastroenterology; Medical imaging; Ostomy
• ISSN: 0002-9270; 1572-0241
• DOI: 10.14309/00000434-201810001-01912

Intentional ingestion of foreign body in adults is not a very common entity that is often associated with psychiatric illness or secondary gain. It offers a clinical problem that may require combined gastrointestinal, surgical and psychiatric interventions. We present a case of intentional ingestion of a metallic shank in a psychiatric patient during prison which had to be removed surgically due to its shape and size. A 24 year old man with history of impulse control disorder presented with 4 days of neck pain. Physical exam showed posterior cervical bony tenderness. Initial chest X-ray revealed a foreign body in the upper abdomen. Plain CT scan of abdomen showed a 13.6 cm undulating metallic foreign body in gastric lumen. Upon further inquiry, patient admitted swallowing a shank while in prison to hide it from the authorities. Subsequent upper endoscopy showed a metallic shank that was twisted in stomach along lesser curvature traversing the pylorus and extending up to junction of first and second part of the duodenum. In view of the shape and large size of the foreign body, retrieval was not attempted. Open gastrostomy was performed by surgery to retrieve the foreign body Deliberate ingestion of foreign bodies is uncommon in adults. It is usually seen in patients with atric issues impulse control disorders or self-mutilating behavior. It can also present in Munchausen syndrome or as an act of malingering, often seen in prisons (as in our patient). Clinically, it may be asymptomatic or may present as signs of esophageal occlusion such as dysphagia, odynophagia, drooling and chest or abdominal pain. Work up involves chest X-ray and CT scan of neck, chest and abdomen. Any suspected secondary gain should be explored while taking the history. Management is largely based on size, type and location of the foreign body. In about 80% of the cases, observation and conservative management is recommended. 20% of the times, EGD is recommended. Emergent EGD is indicated when there are signs of esophageal occlusion (as mentioned above) or risk of esophageal perforation (as in cases of pointed objects or batteries). Only 1% of cases require surgery. Most common complications seen in such cases are impaction and perforation. In conclusion, although most patients can be treated conservatively by observation alone, there should be a low threshold for deciding to proceed to the endoscopic retrieval and surgical intervention in cases of foreign body ingestion.