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Journal of Medical Cases

Case Report

Volume 4, Number 8, August 2013, pages 552-554

Adult Glass Ingestion: A Case Report and Review of Literature

Foreign body ingestion occurs with much greater frequency in children with peak incidence between 6 months to 6 years [1]. Adult foreign body ingestion usually occurs accidently, for example bones with food; however deliberate ingestion accounts for 10% of cases in adults [2]. This pattern is usually repetitive and occurs in patients with intellectual disability, substance abuse, psychiatric disorders, and external motivators (avoidance of jail) [3]. Management of these patients proves to be particularly challenging, therefore a multidisciplinary approach including medical, surgical, and psychiatric interventions is crucial. These patients consume innumerable hospital resources and care can be very costly. In some instances, where underlying psychiatric pathology is identified, certain types of care can be counterproductive.

The majority of the time, 80-90%, the object passes without intervention, 10- 20% of the time endoscopic retrieval is necessary, and in < 1% of cases surgical removal is required [4-9]. Conservative management with close observation is warranted in most cases. Endoscopic removal is efficacious and safe, and is required in situations where conservative management is risky or fails [10]. Risk can be estimated based on the specific situation including type, shape, and location of foreign body, symptomatology, time since ingestion, and evidence of complications including perforation or bleeding [11].

Magnets and batteries provide special challenges. When more than one magnet is ingested they have a tendency to attract each other through the gastrointestinal wall leading to serious complications including bowel necrosis, perforation, obstruction, fistula formation, volvulus, and even death [12]. With battery ingestion comes concerns regarding erosion, perforation, and death. Risks include generation of electrical current, leakage of battery contents, local pressure, and heavy metal toxicity [13].

Absolute indication for surgical intervention is perforation of the gastrointestinal tract. Relative indication includes complications not amendable to endoscopic intervention including objects that are stuck. Anatomical abnormalities including Schatzki ring, hiatal hernia, or in our case restrictive ostomy provide particular challenges [14].

A 31-year-old male presented to the emergency department with a history of hematemesis and diffuse abdominal pain. He reported no relief of this pain with his usual narcotic medications and had been experiencing nausea with an inability to tolerate food or fluids. Vital signs were within normal limits. Complete physical exam revealed a diffusely tender abdomen with no signs of peritonitis. Imaging studies showed no evidence of pneumoperitoneum or pneumomediastinum; however several foreign bodies were visible throughout the gastrointestinal tract (Fig. 1, 2).

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Figure 1. Serial images showing progression of swallowed glass to ileostomy site.

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Figure 2. CT scan showing several glass shards in the stomach and duodenum with no evidence of free fluid or free air.

On further history it was elucidated that life circumstances precipitated a psychiatric crisis, which led to the patient ingesting a broken glass. Review of the patient’s medical chart revealed multiple foreign body ingestions. The patient had visited the emergency department 115 times in the past year with complaints of abdominal pain and had ingested foreign bodies fifteen times in the three weeks preceding the current presentation. On several occasions he was managed with close observation; however he required nine therapeutic endoscopies for definitive management after failure to pass the offending objects or further ingestion of foreign bodies while hospitalized.

The patient’s past medical history was significant for inflammatory bowel disease, chronic abdominal pain, narcotic abuse, depression, previous suicidal ideation, and multiple foreign body ingestions. He was initially thought to have ulcerative colitis and underwent a total colectomy with ileoanal pouch. Subsequently he developed pouchitis and a diagnosis of Crohn’s was made. His pouch was resected and ultimately permanent proctectomy with ileostomy was performed.

On this occasion, the patient was admitted to the GI service for observation. After partially successful endoscopic intervention with failure to pass the remaining glass from his ileostomy, general surgery was consulted and the patient was taken to the operating theatre. Ileoscopy was attempted, and two pieces of glass were identified; however removal was not possible. Therefore laparotomy with adhesiolysis and enterotomy for removal of foreign bodies occurred (Fig. 3).

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Figure 3. Glass shards removed via enterotomy.

The psychiatry liaison service was involved in the care of our patient, as ingestions seemed to be triggered by psychiatric issues. Interestingly, length of patient stay was most affected by this patient’s psychiatric health, rather than delay in endoscopic management or complications related to ingestion. There is some debate as to whether hospitalization may be counterproductive in some instances by reinforcing behaviors. Perhaps outpatient management may be more appropriate if medical and psychiatric states allows.

Most cases of foreign body ingestion can be managed with watchful waiting and close observation. Endoscopic removal is a safe and efficacious option when conservative management is deemed to be too risky, or fails. Surgical intervention is not often required; however provides definitive management in select cases. A multidisciplinary approach is crucial when dealing with repetitive deliberate ingestors, as underlying psychiatric diagnosis is often present.

Competing Interests

The authors declare no competing interests.

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Journal of Medical Cases is published by Elmer Press Inc.