A young woman under psychiatric care in a US hospital had to undergo a colonoscopy after deliberately swallowing multiple nails, reports MedPage Today.
The case was particularly unusual because most cases of foreign body retrieval generally involve the upper gastrointestinal tract (GI).
In this instance the nails lodged in the ileocecal valve between the small and large intestines, said Bhoowit Lerttiendamrong, MD, from the University of Connecticut School of Medicine. The patient was in her 30s and had a history of swallowing foreign bodies.
The medical team elected to remove the nails with colonoscopy, using a hard, transparent cap attached to the distal end of the scope to protect the mucosal lining.
“Using this technique, the nails were successfully removed with only minimal mucosal trauma to the colon,” Lerttiendamrong and colleagues reported in BMJ Case Reports.
He said the case supports the use of a cap to minimise colonic mucosal injury during sharp foreign body removal in the colon.
“It’s pretty rare to have a foreign body that goes all the way down to the lower GI system, and even rarer that sharp foreign bodies go down that far,” he added. “There’s still some limitation, because it’s not a widely proven procedure, but there’s no actual guideline on how to deal with these sorts of cases.”
Intentional swallowing of foreign bodies is seen in patients with advanced age, intoxication, developmental delays, incarceration, or as in this case, psychiatric disorder, the authors wrote. While about 80% of ingested foreign bodies are passed spontaneously, endoscopic retrieval should be considered for patients who don’t respond to conservative management, or in cases involving sharp objects that increase risk for perforation, they noted.
“Nails are especially difficult to remove endoscopically, due to their sharp, irregular shapes, which can make them hard to grasp and may require surgical intervention.”
In cap-assisted endoscopy, a short polymer tube is attached to the distal tip of the endoscope to minimise blind spots during screening colonoscopy, prevent mucosal injuries, and provide an accurate assessment of the lesion size. Only a few reports have described removal of foreign bodies from the lower GI tract, in this case using cap-assisted colonoscopy.
The patient had a history of intentional foreign body ingestion, pica disorder, and anxiety disorder, the authors wrote. She presented with persistent abdominal pain after swallowing multiple nails, her sixth episode of ingesting foreign bodies in the last year.
She was initially managed conservatively, with serial abdominal radiographs every 12 hours, bowel rest, and three litres of polyethylene glycol therapy. The nails were considered to be too far along for safe endoscopic removal.
Repeat imaging showed the nails moved from the mid-abdomen to the right lower quadrant, “ultimately clustering near the ileocecal valve”, they said. After four days with no spontaneous passage, they undertook to remove the nails using cap-assisted colonoscopy.
All eight nails were successfully removed using a snare, “with care taken to secure the sharp ends beneath the cap”, they noted. Inspection of the mucosa after the procedure showed only minor superficial abrasions.
The psychiatry department was consulted on her case, but despite their recommendation that she be admitted, she “adamantly” refused, they wrote. One year later, there have been no further complications after the colonoscopy, and the patient is being followed on an outpatient basis.
Although cap-assisted colonoscopy was successfully used in this case, several technical limitations were identified. For example, advancing the colonoscope with a cap can be “challenging”, particularly in a tortuous or difficult colon, and while the cap protects mucosa from the foreign object, it may cause trauma itself.
“Despite these limitations, this case demonstrates that cap-assisted colonoscopy can be a useful and safe tool for the removal of sharp foreign objects from the colon in clinically stable patients without evidence of perforation or peritonitis, provided that surgical backup is readily available,” the authors concluded.
“This technique should be performed only by experienced endoscopists, as the risk of perforation is significant both before and during the procedure.”
Study details
Intentional nail ingestion with caecal impaction: colonoscopic removal using a cap-assisted technique
Bhoowit Lerttiendamrong, Rachael Hagen, Aaron Kahlam and Alexander Potashinsky.
Published in BMJ Medical Reports Volume 19 Issue 9
Abstract
Most foreign body ingestions in adult patients pass spontaneously while sharp objects often require endoscopic intervention. Endoscopic foreign body removals are usually performed in the upper gastrointestinal (GI) tract, with few reports involving the lower GI tract. We present a case of a woman with recurrent nail ingestion who presented with abdominal pain after swallowing multiple nails. Initial conservative management demonstrated progressive migration, with eventual clustering near the ileocaecal valve. In this case, a cap-assisted colonoscopy was successfully used to remove all ingested nails.
MedPage Today article – Doctors Retrieved Nails From Patient's Bowels (Open access)
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