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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 297-299

The triad of denial, neglect, behavioral disorder causing to habitual multiple foreign-body ingestion – A surgeon's nightmare


Department of Otolaryngology and Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission19-May-2022
Date of Acceptance27-Jun-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Dr. Roshan K Verma
Department of Otolaryngology, Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_113_22

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  Abstract 


Behavioral disorders in children can sometimes lead to habitual and deliberate ingestion of multiple foreign bodies that may be neglected for long periods and require a multidisciplinary team approach to remove them successfully.

Keywords: Dysphagia, gastrostomy, multiple foreign bodies, rigid esophagoscopy, upper gastrointestinal endoscopy


How to cite this article:
Verma RK. The triad of denial, neglect, behavioral disorder causing to habitual multiple foreign-body ingestion – A surgeon's nightmare. Arch Med Health Sci 2022;10:297-9

How to cite this URL:
Verma RK. The triad of denial, neglect, behavioral disorder causing to habitual multiple foreign-body ingestion – A surgeon's nightmare. Arch Med Health Sci [serial online] 2022 [cited 2023 Feb 5];10:297-9. Available from: https://www.amhsjournal.org/text.asp?2022/10/2/297/364948




  Introduction Top


Foreign-body ingestion is common among children and less common among adults.[1] The most common foreign body ingested is fishbone.[2] The incidence of a foreign body is more among patients with psychiatric illnesses.[3],[4] Foreign-body ingestion in adults is usually accidental, except for patients with psychiatric illnesses. The management of foreign bodies at multiple sites often necessitates a multidisciplinary approach. A delay in diagnosis can result in complications.[1],[5]


  Case Report Top


A 19-year-old male with behavioral disorder presented to ear, nose, and throat emergency with absolute dysphagia for 5 days. He did not have any voice change or respiratory difficulty. He had a seizure episode 5 days back. The patient denied abdominal pain, fever, or intoxication with drugs or alcohol. He presented late because his parents initially ignored his complaints as a part of his attention-seeking behavior. However, the attendants gave a history that the child had behavioral issues and had a history of foreign-body ingestion in the past also.

On examination, he was conscious, comfortable, afebrile, and had stable vitals. Indirect laryngoscopy revealed congestion over the left pyriform sinus region with mild pooling of secretions. Bilateral cords were mobile. On neck examination, there was no swelling, emphysema, or tenderness. The rest of the general and systemic examination was normal. The abdomen was soft and nontender. Foreign-body ingestion was suspected and X-ray soft-tissue neck lateral view was done which showed the presence of a metallic foreign body (? razor with a screw) in the upper end of the esophagus [Figure 1].
Figure 1: X-ray STN and X-ray chest AP view and CT neck: Showing metallic foreign body in the neck. X-ray abdomen: Showing suspected metallic foreign body (necklace) in the abdomen. CT: Computed tomography

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An X-ray abdomen was also done revealing another radio-opaque coiled foreign body (suspicious of a pendant) in the stomach [Figure 1].

Contrast computed tomography scan of the neck was done which showed a metallic artifact posterior to cricoid cartilage extending into the esophagus [Figure 1].

Upper gastrointestinal (GI) endoscopy revealed an impacted pencil sharpener in the pyriform sinus, postcricoid region, and upper esophageal sphincter region. Endoscopic removal failed due to difficulty in instrumentation.

The patient was taken to OT and was then intubated. Initially, removal of the foreign body was attempted. Hypopharyngoscope was introduced and a metallic foreign body (sharpener) was found in the postcricoid region pushing the arytenoid anteriorly. It was pulled into the lumen of the hypopharyngoscope (acting as an overtube) and was removed. Postremoval, examination revealed ulceration in the posterior wall of the esophagus[Figure 2].
Figure 2: Intraoperative picture showing sharpener lodged just below cricopharynx

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The abdominal foreign was removed by a surgical gastroenterologist. Gastrostomy was performed and two separate foreign bodies – A toothbrush and a charging wire were removed from the stomach [Figure 3].
Figure 3: Intraoperative picture of laparotomy showing toothbrush and mobile charger wire removed from the stomach

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A total of three foreign bodies were removed.

  1. Sharpner – measuring 3 cm × 2 cm × 1.5 cm
  2. Toothbrush – length measuring 22 cm
  3. Charging wire – 4 mm circumference and 20 cm in length


Postsurgery, extubation was uneventful and the patient was shifted to the ward. He was discharged in a satisfactory condition after observation.


  Discussion Top


The diagnosis of foreign-body ingestion in adults is often straightforward. Intentional ingestion of a foreign body is uncommon. It is seen in patients with psychiatric illnesses which include schizophrenia, autism, pica, and personality disorders.[3],[6] In our case, the patient did not complain of ingestion but had multiple foreign bodies present in his gastrointestinal tract. The psychiatric evaluation revealed the presence of behavioral problems since childhood. Hence, his complaint of absolute dysphagia was considered an attention-seeking behavior and ignored by his parents, leading to a delay in receiving medical attention. It is important to get a psychiatric evaluation in such peculiar cases. Delay in presentation often leads to complications such as mediastinitis, perforation peritonitis, hemorrhage, abscesses, and leakage of toxic substance from a foreign body.[1],[2],[7]

Radiology is vital for the diagnosis of foreign bodies and also helps in identifying complications such as mediastinitis and intestinal perforation.[8],[9],[10],[11] Evaluation of the whole GI tract from pharynx to rectum is often necessary to rule out the presence of multiple objects. However, radiology can be misleading as only radio-opaque objects are readily identifiable.[11] In our case, the plastic covering the blade of the sharpener was not identified as it was radiolucent. Similarly, only the bristle of the brush was identifiable.

The most common and noninvasive method for foreign body removal is flexible endoscopy.[7],[12],[13],[14] It is often preferred in cooperative individuals without any complications. Various endoscopic modalities available include over tube technique, dormia basket, Radial Jaw forceps, and polypectomy snare.[12] It is not useful if the object is large or has sharp edges which might result in trauma.

Rigid esophagoscopy is the instrument of choice for the esophageal foreign body.[13],[14] In our case, the lumen of the esophagoscope was inadequate for both complete visualization as well as instrumentation. We used hypopharyngoscope for retrieval of the cricopharyngeal foreign body. Larger luminal dimensions provided ample space for endoscopic examination as well as instrumentation.

Surgical removal of the foreign body is performed only in selected cases.[11],[15] If a foreign body is small, blunt, located distal to the gastroduodenal junction, and do not pose a threat of obstruction or perforation, conservative management can be opted for.[7] Objects usually pass through the intestinal tract and get evacuated in feces. This is not preferable for large objects and objects that have a potential for complication.[1],[2] In our case, the decision for surgical removal was based on the fact that the object was large on imaging, and attempted endoscopic removal could lead to perforation at the level of the upper esophagus where the sharpener was impacted as the mucosal injury was already noted. The procedure was uneventful and the foreign bodies could be retrieved.

This patient did not have complications often seen with delayed presentation. The presence of complications makes the management cumbersome which may require gastric bypass, intensive care unit care, long hospital stay, mediastinitis, and sepsis, thereby resulting in morbidity and mortality.[2],[5] Postoperatively, our patient was allowed orally on day 2 and discharge was one on day 4 after 72 h of close observation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shivakumar AM, Naik AS, Prashanth KB, Yogesh BS, Hongal GF. Foreign body in upper digestive tract. Indian J Pediatr 2004;71:689-93.  Back to cited text no. 1
    
2.
Lai AT, Chow TL, Lee DT, Kwok SP. Risk factors predicting the development of complications after foreign body ingestion. Br J Surg 2003;90:1531-5.  Back to cited text no. 2
    
3.
Gitlin DF, Caplan JP, Rogers MP, Avni-Barron O, Braun I, Barsky AJ. Foreign-body ingestion in patients with personality disorders. Psychosomatics 2007;48:162-6.  Back to cited text no. 3
    
4.
Rashid F, Davies L, Iftikhar SY. Magnetised intragastric foreign body collection and autism: An advice for carers and literature review. Autism 2010;14:139-45.  Back to cited text no. 4
    
5.
Unruh BT, Nejad SH, Stern TW, Stern TA. Insertion of foreign bodies (polyembolokoilamania): Underpinnings and management strategies. Prim Care Companion CNS Disord 2012;14:PCC.11f01192. doi: 10.4088/PCC.11f01192. Epub 2012 Feb 16.  Back to cited text no. 5
    
6.
Martindale JL, Bunker CJ, Noble VE. Ingested foreign bodies in a patient with pica. Gastroenterol Hepatol (N Y) 2010;6:582-4.  Back to cited text no. 6
    
7.
Weiland ST, Schurr MJ. Conservative management of ingested foreign bodies. J Gastrointest Surg 2002;6:496-500.  Back to cited text no. 7
    
8.
Pinto A, Muzj C, Stavolo C, Pepe M, Cinque T, Romano L. Pictorial essay: Foreign body of the gastrointestinal tract in emergency radiology. Radiol Med 2004;107:145-52.  Back to cited text no. 8
    
9.
Zitzmann NU, Elsasser S, Fried R, Marinello CP. Foreign body ingestion and aspiration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:657-60.  Back to cited text no. 9
    
10.
Okan İ, Akbaş A, Küpeli M, Yeniova AÖ, Esen M, Özsoy Z, et al. Management of foreign body ingestion and food impaction in adults: A cross-sectional study. Ulus Travma Acil Cerrahi Derg 2019;25:159-66.  Back to cited text no. 10
    
11.
Shaariyah MM, Goh BS. Retrospective review of surgical management of foreign body ingestion. Med J Malaysia 2009;64:307-10.  Back to cited text no. 11
    
12.
Faigel DO, Stotland BR, Kochman ML, Hoops T, Judge T, Kroser J, et al. Device choice and experience level in endoscopic foreign object retrieval: An in vivo study. Gastrointest Endosc 1997;45:490-2.  Back to cited text no. 12
    
13.
Gmeiner D, von Rahden BH, Meco C, Hutter J, Oberascher G, Stein HJ. Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus. Surg Endosc 2007;21:2026-9.  Back to cited text no. 13
    
14.
Henderson CT, Engel J, Schlesinger P. Foreign body ingestion: Review and suggested guidelines for management. Endoscopy 1987;19:68-71.  Back to cited text no. 14
    
15.
Barros JL, Caballero A Jr., Rueda JC, Monturiol JM. Foreign body ingestion: Management of 167 cases. World J Surg 1991;15:783-8.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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