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MULTI-ORGAN DYSFUNCTION RESULTING FROM AN UNUSALLY LARGE METALLIC INGESTION
C Gillis, R Abaskharoun
Several groups are at risk of intentional ingestion. Eighty percent of ingestion is in the pediatric population; however, in adults those with psychiatric disorders and those seeking secondary gain are at risk. Patients with psychiatric disorders often swallow multiple objects over multiple occasions.
Between 80 and 90% of Gastrointestinal foreign bodies pass spontaneously without causing harm. Objects that did not pass have been associated with a mortality approaching 50%. Up to 1500 deaths per year are attributed to ingested foreign bodies. Perforation and obstruction are the most common presenting symptoms. Objects that are five centimeter long and greater than two centimeter wide are unable to pass the GI tract.
This is the case of a 48 year old male who was sent to hospital with fatigue and falls and was found to have pancytopenia, hepatitis and acute renal failure. Plain films and CT scan demonstrated that the gastric body was filled with innumerous metallic objects, and had signs of distal partial small bowel obstruction, but no convincing evidence of free air. GI had been consulted for consideration of endoscopic removal , but given the size and number of the objects, this was declined and a surgical approach was taken given the patient was developing increasing abdominal distention and symptoms compatible with lead poisoning and multi-organ failure. The operation revealed a contained perforation of the greater curve. A gastrotomy was done and objects including coins, nuts, bolts, necklaces, earrings, bracelets, batteries, bullets and nail clippers were removed. Multiple pens were removed including one approximately two and a half feet long, which was the one which had perforated the stomach. The small bowel was inspected and a battery was removed from the mid small bowel. Post operative care in the ICU was surprisingly uneventful. Follow up visits confirmed the patient was doing well except an incisional hernia. Flat plate x-rays did show ingestion of some further metallic objects but these were small and felt to be best managed conservatively.
Metallic ingestion is not uncommon among the psychiatric population, but the presentation with such quantity of ingestion and multi-organ failure is unusual. Ongoing surveillance will be required.