Reviewer: A. Kumar, M.D., Cleveland Clinic
A 24-year-old female presented to the emergency room (ER) with a complaint of swallowing a pen two days ago. She has had vomiting and epigastric pain since then. The patient has a long history of similar behavior in the past. During the last admission one month ago, she had an esophagogastroduodenoscopy (EGD) with a pen removal followed by a spoon ingestion on the ward, requiring a second endoscopy. She also reports eating "a call button" at another facility recently, "they said it was in my colon." She denies being suicidal.
Past medical history (PMH)
Post-traumatic stress disorder (PTSD), depression, intentional foreign body (FB) ingestions, heroin abuse.
Past surgical history (PSH)
Open foreign body (FB) removal 4 times in the past.
Social history (SH)
Smoking, heroin IV abuse.
Vital signs - stable (VSS).
What would you do?
Complete blood count (CBC), basic metabolic panel (BMP).
X-ray of kidneys, ureters, and bladder (KUB).
Current KUB: Excessive stool is present in the colon. There is a right-sided groin catheter. Overlying the stomach or perhaps within the stomach is a linear lucency measuring approximately 12.5 cm. It has a metal tip (click to enlarge the images).
Previous KUB from one month ago: The call button is located in the right upper quadrant, ejecting over both the duodenum and colon. There is no free air. The bowel gas pattern is nonobstructive. There is a right-sided groin catheter (click to enlarge the images).
Plain X-ray films were reviewed with radiology: there was a metallic FB in the stomach that looked like a pen tip, there was also a metallic FB in transverse colon, no evidence of perforation or obstruction.
The patient was admitted to a general medicine floor with a sitter. Psychiatry and GI consults were called. The pen was removed through an EGD.
Foreign body ingestion.
Gastric foreign body (toothbrush) seen on endoscopy. Image source: Wikipedia, public domain.
Bladder Foreign Body. NEJM, 06/2008.
There Was a Young Man Who Swallowed a Nail...Perhaps He'll Die. Medscape, 12/2008.
Foreign Objects Found in Patients: Slideshow. Medscape.
Swallowed Objects That Went Straight Into History - NYTimes, 2011.