Transcript Correctional Medicine Case Study: Intentional Foreign Body

Correctional Medicine Case Study:
Intentional Foreign Body Ingestion
Alexis Yakich
October 25th, 2007
The facility…
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Huntingdon State Correctional Institution
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2nd most death row inmates in the state of Pennsylvania
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Estimated 88% have been diagnosed with a psychiatric
disorder.
The patient…
Ok just kidding…the real patient
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46 year old male with a history of
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Antisocial Personality Disorder
Impulse Control Disorder
Severe psychosis
as well as seborrheic dermatitis, hypothyroidism,
hypertrigylceridemia, and Hepatitis C
Medications included
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Lithium CO3 300 mg every morning
Lithium CO3 460 mg every night
Risperdol 6 mg daily
Thorazine 100 mg QID
Synthroid 88 mcg daily
Hydrocortisone 2.5% BID, Lubriderm Lotion daily, Maalox 30 cc
TID, Dulcolax 5 mg BID, Lopid 600 mg BID, Demerol 100 mg
daily
Just a little personality background
information…
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Patient hospitalized after refusing 21
meals straight (7 days) and was fed via
NG tube
Patient placed in observation cell at least
once weekly for the past 34 weeks due to
suicidal and homicidal threats
The case…
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Patient informed a correctional officer of
intentionally ingested foreign bodies including a
toothbrush, 3 staples, and a flex pen
The abdominal xrays showed:
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A foreign body in the epi-gastric region that is
oriented obliquely and is consistent with a pen with a
plastic body and metallic point.
Additionally in the right lower quadrant, another
foreign body was discovered that appeared to be an
approximately 4 cm piece of metallic wire
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At this point…
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The patient was having normal bowel
movements, not vomiting, and denied any
abdominal pain…so we decided on
observational measures and to let nature take
it’s course.
6 days later…
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All had been passed in bowel movements except the flex
pen.
Abdominal films ordered, which revealed the presence of
only the ball point pen measuring approximately 9 cm in
the ascending colon.
Still having normal bowel movements and no symptoms
of bowel obstruction.
The next day another set of abdominal films
ordered…the pen had not moved. It was also noted at
this time there was still no evidence of bowel
obstruction, no free air in the peritoneal cavity and the
intestinal gas pattern was unremarkable.
Ok now what?
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After an additional consult with the attending general surgeon it was
decided due to the immobility of the object after 24 hours that the
patient would be admitted for removal of the foreign body via
colonoscopy
The physical exam was completely unremarkable upon admission.
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Vitals were as follows: 98.8 degrees F, heart rate 88, respiratory rate
20, blood pressure 140/98 mmHg.
The patient’s abdomen was soft, non-distended, and non-tender to
palpation. Normal active bowel sounds were heard in all four
quadrants.
The patient was started on 2 liters of GoLitely Solution and prepped for
surgery
Colonoscopy/Fishing Time…
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Anesthesia was given for conscious sedation and the
colonoscope was introduced through the anus and
advanced to the cecum, identified by appendiceal orifice
and IC valve.
A 9 cm foreign body, later identified as a ballpoint pen
was retrieved from the ascending colon using Magill
forceps.
No bowel perforation, polyps, or diverticula were noted.
Estimated blood loss was minimal and the patient
tolerated the procedure well.
The patient received a status post operative follow up
visit, but will not need any additional treatment.
Literature Review
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The majority of foreign body ingestion is
commonly seen in:
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children (80%)
the elderly
or mentally impaired individuals and is accidental
HOWEVER--prisoners and psychiatric patients have
been known to intentionally swallow objects to
impose transfer to a hospital from a prison or
psychiatric institution or as a suicide attempt
What happens when you swallow
something you aren’t meant to?
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Approximately 90% of ingested foreign bodies pass through the
gastrointestinal tract without complication with close observation
10-20% necessitate endoscopic removal
Only about 1% will need surgical intervention
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The diagnosis is usually made through the patient’s history.
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In patients unable to provide a verbal history, a sudden refusal to
eat or respiratory symptoms that include coughing or wheezing due
to aspiration are reasons to add foreign body ingestion to a list of
differential diagnoses.
Objects that have passed through the esophagus normally do not
cause any noticeable symptoms unless perforation or obstruction
occurs.
For this reason, a vigilant physical examination should be executed
to assess symptoms of subcutaneous emphysema, peritoneal signs,
abdominal distention, and pain/tenderness on palpation
Where is the object, and how is it
removed?
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Endoscopic removal is indicated if the foreign body is
anterior to the small bowel, if the object is located
proximal to the upper esophageal sphincter should be
removed by an otolaryngologist
Just Observation?
Observation is recommended for objects that have
passed further than the gastroesophageal
junction.
Past the LES…
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If the foreign body:
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causes perforation or obstruction of the bowel
OR
if the object remains at a stationary point
relative to the bowel confirmed by two
abdominal radiographs taken 24 hours apart,
surgical intervention is recommended, either
by means of colonoscopy or by an open
procedure
Some potential intestinal difficulties…
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Generally:
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objects with a diameter over 2 cm will not pass
through the pylorus or ileocecal valve, which are both
physiological narrowing’s
objects more than 5 cm in length will not bypass the
duodenal sweep, a physiologic angulation.
Another problem with the pen…
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Long foreign bodies (like pens) are
challenging to retrieve, due to the length
of the object and the difficulty of
intraluminal manipulation
SO….
DON’T EAT ONE!
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Resources:
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T.E. Pavlidis, G.N. Marakis, A. Triantaflyllou, K. Psarras, T.M.
Kontoulis, A. K. Sakantami : Management Of Ingested Foreign
Bodies : How Justifiable Is A Waiting Policy?. The Internet
Journal of Surgery. 2007. Volume 9 Number 1.
First Consult: Foreign Body in the Ear, Nose, GI, Vagina. Elsevier
Limited. 2007.
D. B. Christie, W.D. Luke, S. Sedghi: Ingested Foreign-Body
Retrieval: A Novel New Method. Gastrointestinal Endoscopy.
January 2007. Volume 65 Issue 1.
Pasricha, P. (2004) Goldman: Cecil Textbook of Medicine. St
Louis: W. B. Saunders Company.