|Year : 2019 | Volume
| Issue : 2 | Page : 103-106
Multiple foreign body ingestion in pica patient
Ankita Chauhan, Vandana Verma Ahluwalia, Prerna Singh Saharan, Shamrendra Narayan, Neelmani Sharma
Department of Radiodiagnosis, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||17-Sep-2019|
Dr. Ankita Chauhan
Department of Radiodiagnosis, Sarojini Naidu Medical College, Agra - 282 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Appetite for substances that are widely non-nutritive is termed Pica and commonly seen in patients with psychiatric disorders. Their clinical presentation may be delayed and include multiple foreign bodies. Most of such ingested bodies pass through gastrointestinal tract uneventfully and only on rare instances cause obstruction or perforation. The length and sharpness of an object govern its risk of perforation. Physicians are dependent upon imaging to detect a foreign body, especially if the history of ingestion is doubtful. We present a case of pica with multiple foreign bodies diagnosed on radiography and ultrasonography with the findings correlating with surgical retrieval of objects.
Keywords: Foreign body ingestion, pica, radiograph, ultrasonography
|How to cite this article:|
Chauhan A, Ahluwalia VV, Saharan PS, Narayan S, Sharma N. Multiple foreign body ingestion in pica patient. J Mahatma Gandhi Inst Med Sci 2019;24:103-6
|How to cite this URL:|
Chauhan A, Ahluwalia VV, Saharan PS, Narayan S, Sharma N. Multiple foreign body ingestion in pica patient. J Mahatma Gandhi Inst Med Sci [serial online] 2019 [cited 2020 Jan 20];24:103-6. Available from: http://www.jmgims.co.in/text.asp?2019/24/2/103/267014
| Introduction|| |
The pediatrics, emergency surgery, and gastroenterology units frequently have cases of foreign body ingestion. Psychiatric patients can swallow a wide variety of indigestible objects. Physicians must be familiar with signs and symptoms of the ingested foreign body, especially in these patients wherein no history of such episodes of ingestion is available.
| Case Report|| |
We present a case of a 24-year-old man with a history of psychiatric illness who was on antidepressant medications for the past 1 year. On a previous outpatient visit, the patient's attendant gave an account of abdominal distension and altered bowel habits. The patient was uncommunicative; however, vitals were stable as were laboratory tests, excluding any drug-related side effects. Erect abdomen radiograph showed multiple metallic foreign bodies with dilated small bowel loops [Figure 1]. There was no radiological evidence of peritonitis, pneumoperitoneum, or intestinal obstruction. The patient showed stable vitals and was under observation, but left against the medical advice. After 15 days, the patient represented with a complaint of pain. Repeat erect abdomen radiograph showed an increase in number with a change in position of multiple metallic foreign bodies clumped in the right side of the abdomen that correlated with the visible lump in the right iliac fossa [circled in [Figure 2]. The ultrasonographic (USG) evaluation of the right iliac fossa confirmed the presence of echogenic elongated relatively well-defined intrabowel foreign body with associated reverberation artifacts [Figure 3]. The foreign body is seen perforating the bowel wall, with a small collection localized around it, suggesting sealed perforation. There was no ascites. A well-defined linear foreign body is seen penetrating the right lateral wall of the urinary bladder, with its sharp leading end being inside the bladder lumen and the blunt end in the perivesical region with a small associated focal collection [Figure 4]. Blood investigations show borderline normocytic anemia, mild thrombocytopenia (126,000 cells/mm3), borderline hyperkalemia (5.9 mEq/L), and mildly raised serum creatinine (1.3 mg/dL). His stool tested positive for the hemoccult fecal occult blood test. The patient underwent surgical explorative laparotomy, and multiple foreign bodies were recovered [Figure 5] with radiograph and ultrasound findings correlating well with operative findings.
|Figure 1: Erect abdomen radiograph showing multiple metallic foreign bodies (arrows). Small bowel loops showing mild dilatation. However, there is no evidence of multiple air-fluid levels or free gas under domes of the diaphragm|
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|Figure 2: Repeat erect abdomen radiograph done after 15 days showing (a) an increase in number with a change in position of multiple metallic foreign bodies (arrows) clumped in the right side of the abdomen that correlated (b) with the visible lump in right iliac fossa (circled)|
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|Figure 3: Ultrasonogram of right iliac fossa region showing an echogenic elongated relatively well-defined intrabowel foreign body with associated reverberation artifacts. The foreign body is seen perforating the bowel wall, with a small collection localized around it, suggesting sealed perforation|
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|Figure 4: Ultrasonogram showing a well-defined linear foreign body penetrating the right lateral wall of the urinary bladder, with its sharp leading end being inside the bladder lumen and the blunt-end in the in the perivesical region with a small associated focal collection. Radiographs suggest a change in position of the foreign body (arrows) with bladder volume status|
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| Discussion|| |
Pica is a recurrent consumption of nonnutritive, nonfood items. To be called pica, these behaviors must last at least for a month. If consumption is developmentally or culturally appropriate (for example, it is a common practice in Africa to eat white clay), it is not pica.
Pica shows an association with nutritional deficiency (iron, calcium), pregnancy, and psychological factors (such as poverty, maternal neglect, child abuse, lack of parental supervision, or a chaotic family situation). Autism, mental retardation, depression or anxiety disorder, paranoid schizophrenia, impulse control disorder, substance abuse disorder, posttraumatic stress disorder, and antipsychotics (such as olanzapine and risperidone) can also induce pica., Studies have shown worsening of pica by neuroleptic drugs and improvement by prescription of dopamine agonist (methylphenidate)/partial agonist (aripiprazole).,
Pica needs to be ruled out in a psychiatric patient with bowel obstruction of an unknown cause, particularly in mentally retarded patients to prevent potential death or otherwise severe chronic consequences., These patients are more likely to ingest multiple objects and can be repeat offenders, as seen in our case. One study showed 11% mortality rate in 35 pica patients with 56 total ingestions. In 75% of these cases, surgical intervention was unavoidable. Therapeutic approach should aim at early recognition and multidisciplinary management of the psychological stressors or triggers potentially responsible for pica.
Ingested foreign bodies that pass into the stomach will traverse the rest of the gut uneventfully in >80% of cases. Common location for ingested foreign body impaction is cricopharynx, midesophagus, lower esophageal sphincter, pylorus, ileocecal valves of Houston, and the anal sphincter. Objects longer than 6 cm in length are difficult to pass through the C-loop of the proximal duodenum, and objects as small as 2 cm in length may get stuck in the pylorus., Objects that are pointed or have sharp ends may stick or pierce the mucosa and have a relatively slow transit time compared to rounded blunt objects which are expected to have a relatively shorter transit in the gastrointestinal tract (GIT). The risk of perforation from an ingested sharp object depends on upon its size and orientation, and its significance lies in early detection and treatment.
Although perforation can occur anywhere in the GIT, distal ileum is the most common site of perforation followed by ileocecal junction, left colon, and at the rectosigmoid junction due to their angulations.,
Bowel perforations caused by the foreign body may present with abdominal pain (95%), fever (81%), or peritonitis (39%), mimicking acute intestinal conditions such as acute appendicitis, acute diverticulitis, and perforated peptic ulcer.
If objects fail to pass through the gut in 3–4 weeks, the foreign body may adhere to the mucosa secondary to reactive fibrinous exudates, with a possible migration of objects extraluminally to unusual locations. After a foreign body has perforated a hollow viscus, it could lie inter/extra-luminal near the perforation site or adjacent/distant organs to perforate again or could pass out without complication.
Physicians are dependent upon imaging to detect foreign objects, more so in cases where the history of ingestion is doubtful.
The first investigation usually is a radiograph to localize the site of the ingested foreign body. Radiograph has been found useful in a large number of cases as accidentally most swallowed foreign bodies are radiopaque and well appreciable.
Plain radiographs fail to detect radiolucent foreign bodies such as plastic, certain types of glass, fish bones, and thin metallic objects, in which X-ray beam alignment is not in a proper direction. It offers limited data regarding the sharpness of an object.
Ultrasound can be helpful to evaluate the radiolucent foreign body-related symptoms associated with ingestion such as local peritonitis and perforation. In our case, detection of focal perforation of the urinary bladder by ultrasound in an asymptomatic patient guided the surgeon to take appropriate measure perioperatively. However, if urinary bladder perforation by a foreign body is suspected, cystoscopy may be of benefit to determine the extent of the invasion.
If pica is secondary to treatable internal diseases, treatment of the underlying disease is necessary. Cooperation between specialists (psychiatrists, general practitioners, surgeons, and gastroenterologists) is essential as there may be somatic consequences that require urgent care. In primary cases of pica, psychotherapy is fundamental. Studies show that pica behavior can be decreased substantially with behavioral treatment (positive and negative reinforcements) and counseling., Taking into consideration that eating is repetitive, egodystonic, intrusive, it is postulated that pica lies in the obsessive–compulsive spectrum and hence responds to selective serotonin reuptake inhibitors (fluoxetine and sertraline)., In case of pica secondary to nutritional deficiency, supplementation of vitamin and mineral affects the potency of behavioral intervention in patients with intellectual disability.
In schizophrenic patients, pica presents as a rare, independent, and discrete behavior, but it is frequently missed in the diagnosis, and as a result, complications such as intestinal obstruction, electrolyte disturbances, and heavy metal poisoning may occur.
The caregivers of mentally impaired patients should carefully watch out for foreign bodies ingestion, particularly in those with a prior history of pica and ingestion of multiple objects. Surgical removal is essential for the swallowed objects that are too large, numerous, or dangerous for endoscopic retrieval.
Postoperative adhesions are well known in these patients following abdominal surgeries and pose a challenge to surgeons if the patient undergoes another surgery. For the prevention of future episodes, diligent efforts are required, including psychiatric counseling or psychotropic drugs if necessary, with regular follow-up.
Comorbidities significantly potentiate the problem of people with an intellectual impairment. Therefore, an accurate psychological assessment of multiple diagnoses is useful in detecting the specific underlying processes and in planning an appropriate management and rehabilitation program.
| Conclusion|| |
In unsuspected cases, foreign body perforation is difficult to diagnose without an aid of imaging modalities. Imaging is also helpful in situations where history cannot be taken appropriately as in children and psychiatric patients. A high index of clinical suspicion is needed as many foreign bodies are not radiopaque and cannot be picked up in radiographic investigations. Further imaging with ultrasound is helpful, which is readily available and quick to perform in an emergency room. Ultrasound is not only useful for detecting nonradiopaque foreign bodies but also for assessing associated localized, changes which can ensure an uneventful treatment and postoperative period. In metallic and multiple abutting foreign bodies, USG is more useful than computed tomography (CT) because CT-associated dense streak artifacts obscure the anatomical details.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Michalska A, Szejko N, Jakubczyk A, Wojnar M. Nonspecific eating disorders-a subjective review. Psychiatr Pol 2016;50:497-507.
Tokue H, Takahashi Y, Hirasawa S, Awata S, Kobayashi S, Shimada T, et al.
Intestinal obstruction in a mentally retarded patient due to pica. Ann Gen Psychiatry 2015;14:22.
Thimmaiah VT, Raman R, Balraj S, Kumar KS, Shilpa D. Imaging findings of fish bone complicating as intraabdominal abscess with review of literature. World J Res Rev 2016;2:31-4.
Alex C, Venkatarangan KS, Benny A. Girl with trichobezoar – A case report. Indian J Basic Appl Med Res 2016;6:368-70.
Chawla N, Charan D, Kumar S, Pattanayak RD. Pica associated with initiation of atypical antipsychotic drugs: Report of two cases. Psychiatry Clin Neurosci 2016;70:363-4.
Hergüner A, Hergüner S. Pica in an adolescent with autism spectrum disorder responsive to aripiprazole. J Child Adolesc Psychopharmacol 2016;26:80-1.
Martindale JL, Bunker CJ, Noble VE. Ingested foreign bodies in a patient with pica. Gastroenterol Hepatol (N
Muensterer OJ, Joppich I. Identification and topographic localization of metallic foreign bodies by metal detector. J Pediatr Surg 2004;39:1245-8.
Chen MK, Beierle EA. Gastrointestinal foreign bodies. Pediatr Ann 2001;30:736-42.
Velitchikov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies in the gastrointestinal tract: Retrospective analysis of 542 cases. World J Surg 1996;20:1001-5.
Knight LC, Lesser TH. Fish bones in the throat. Arch Emerg Med 1989;6:13-6.
Samuel DO, Adegboyega OF, Ene OM. Spontaneous expulsion of ingested foreign bodies: case series and review of literature. Am J Med Case Rep 2015;3:272-5.
Kalimuthu V, Krishnaswamy J, Samraj A, Jayavelu R. Pericolic abscess due to large bowel perforation by fish bone – A case report. Int J Recent Trends Sci Technol 2015;13:516-8.
Rodríguez-Hermosa JI, Codina-Cazador A, Sirvent JM, Martín A, Gironès J, Garsot E, et al.
Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Dis 2008;10:701-7.
Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, et al.
Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006;30:372-7.
Gundogar D, Demir SB, Eren I. Is pica in the spectrum of obsessive-compulsive disorders? Gen Hosp Psychiatry 2003;25:293-4.
Pace GM, Toyer EA. The effects of a vitamin supplement on the pica of a child with severe mental retardation. J Appl Behav Anal 2000;33:619-22.
Kar SK, Kamboj A, Kumar R. Pica and psychosis – Clinical attributes and correlations: A case report. J Family Med Prim Care 2015;4:149-50.
] [Full text]
Di Nuovo SF, Buono S. Psychiatric syndromes comorbid with mental retardation: Differences in cognitive and adaptive skills. J Psychiatr Res 2007;41:795-800.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]