Multiple Sharp object ingestion
1
“Iron Toxicity” Sharp Object Ingestion by Schizophrenic Patient Baran Palanimuthu, Alzamani Idrose Introduction Ingestion of multiple sharp objects Is a rare presentation. We present such a case in a schizophrenia patient. Case Description 25 years old malay gentleman who is also a schizopherenic and antisocial personality disorder with history of 2 laparotomy done in Jan 2012 and May 2015 respectively for removal of foreign body presented to our emergency department with complaint of abdominal pain more over right hypochondriac region and left lumbar region. He claimed that he was having auditory hallucination, a voice asked him to ‘eat scissors, nail clipper and long screw’.His vital signs were normal ,upon examination he was not aggressive and had a good eye contact. Apart from delusion, he did not manifest any other abnormalities, his speech were coherent and rational. Patient had poor insight of his condition. On abdominal examination, noted mild tenderness over right hypochondriac and left lumbar region, no guarding. Digital rectal examination-Brownish stool. Abdominal x-ray showed opaque object in the form of long screw,a nail clipper and clasped scissors. Proceeded with On table endoscopy, laparotomy, adhesiolysis, enterotomy and removal of foreign body by surgical team. Intra-op Findings: 1.“ Folded scissors and rubber/leather band ” in fundus - gastrostomy done 2.Long screw about 10 cm and chained nail clipper at DJ – enterotomy done and FB removed 3.Large bowel palpated up to ICJ, no foreign body noted 4.Fluroscopy after enterotomy and removal showed no foreign body remain. Post surgery patient recovered in surgical ward for 1 week while psychiatry team assessed patient regularly. Patient completed 1 Week of antibiotic course and discharged well .Given appointment 2 weeks to psychiatry clinic upon discharge. No change in behaviour/suicidal intention / attempt in FB ingestion through out admission in ward. Discussion Sharp object ingestion is a rare condition in emergency department. However it is not impossible especially when patient has underlying psychiatry disorder ,in this case shizophrenia. When a psychiatry patient claims that he/she ingested sharp objects, serious attention should be given. Radiologic imaging such as abdominal x-ray able to rule out Iron sharp objects ingestion as in this case long screw,clasped scissors and long nail appear as radioopaque image.Sharp object ingestion is a life threatening condition especially when it perforate GI tract which can lead to peritonitis/ internal bleeding. Hence immediate surgical intervention and psychiatry team review is required ,in this case surgical team immediately proceeded with on table endoscopy, laparotomy, adhesiolysis, enterotomy and removal of foreign body. Continuous vital sign monitoring and behaviour chart should be done to ensure patient is stable before and after surgery. This patient was observed for 1 week in surgical ward, completed 1 week course of IV antibiotic. Regular assessment by psychiatry team was done. Discharged well after 1 week and given appointment after 2 weeks to psychiatry clinic. Continuous follow up under psychiatric team and optimization of medication is crucial for this patient to prevent further attempt of sharp object ingestion. Lessons Learnt & Conclusion This is rare case of recurrent ingestion of sharp objects following hallucination and poor insight of illness. Imaging is necessary in such case. Laparatomy is required as objects ingested were sharp and potentially damaging to bowel. Proper psychiatry management is needed in this case to avoid recurrence References 1.Henry K . Ingestion of sharp foreign object:A Case series Literature review and management recommendation. Journal of gastric disorder and therapy.2015 1.1, 1-4 2. Gitlin DF1, Caplan JP, Rogers MP, Avni-Barron O, Braun I, Barsky AJ. Foreign-body ingestion in patients with personality disorders. Psychosomatics.2007 Mar-Apr;48(2):162-6. 3.Mehran et al(2005) Gastric perforation secondary to ingestion of a sharp foreign body.Journal of the society of Laparoendoscopic surgeon.2005 9(1) ,91-93 Department of Emergency Medicine and Trauma Hospital Kuala Lumpur, Kuala Lumpur 50586 MALAYSIA
-
Upload
baran-palanimuthu -
Category
Documents
-
view
12 -
download
0
description
Multiple Sharp object ingestion by schizopherenic patient--> removed surgicallycase reported in Emergency Department ,Kuala Lumpur General hospitalCase presented in 4th International Clinical Conference in Emergency Medicine 2015
Transcript of Multiple Sharp object ingestion
“Iron Toxicity”Sharp Object Ingestion by Schizophrenic Patient
Baran Palanimuthu, Alzamani Idrose
IntroductionIngestion of multiple sharp objects Is a rare presentation. Wepresent such a case in a schizophrenia patient.
Case Description25 years old malay gentleman who is also a schizopherenic andantisocial personality disorder with history of 2 laparotomy done inJan 2012 and May 2015 respectively for removal of foreign bodypresented to our emergency department with complaint ofabdominal pain more over right hypochondriac region and leftlumbar region.
He claimed that he was having auditory hallucination, a voice askedhim to ‘eat scissors, nail clipper and long screw’.His vital signswere normal ,upon examination he was not aggressive and had agood eye contact. Apart from delusion, he did not manifest anyother abnormalities, his speech were coherent and rational. Patienthad poor insight of his condition. On abdominal examination, notedmild tenderness over right hypochondriac and left lumbar region,no guarding. Digital rectal examination-Brownish stool. Abdominalx-ray showed opaque object in the form of long screw,a nail clipperand clasped scissors.
Proceeded with On table endoscopy, laparotomy, adhesiolysis,enterotomy and removal of foreign body by surgical team.
Intra-op Findings:1.“ Folded scissors and rubber/leather band ” in fundus -gastrostomy done2.Long screw about 10 cm and chained nail clipper at DJ –enterotomy done and FB removed3.Large bowel palpated up to ICJ, no foreign body noted4.Fluroscopy after enterotomy and removal showed no foreignbody remain.
Post surgery patient recovered in surgical ward for 1 week whilepsychiatry team assessed patient regularly. Patient completed 1Week of antibiotic course and discharged well .Given appointment2 weeks to psychiatry clinic upon discharge. No change inbehaviour/suicidal intention / attempt in FB ingestion through outadmission in ward.
DiscussionSharp object ingestion is a rare condition in emergency department.However it is not impossible especially when patient has underlyingpsychiatry disorder ,in this case shizophrenia. When a psychiatrypatient claims that he/she ingested sharp objects, serious attentionshould be given.
Radiologic imaging such as abdominal x-ray able to rule out Ironsharp objects ingestion as in this case long screw,clasped scissorsand long nail appear as radioopaque image.Sharp object ingestionis a life threatening condition especially when it perforate GI tractwhich can lead to peritonitis/ internal bleeding.
Hence immediate surgical intervention and psychiatry team reviewis required ,in this case surgical team immediately proceeded withon table endoscopy, laparotomy, adhesiolysis, enterotomy andremoval of foreign body.
Continuous vital sign monitoring and behaviour chart should bedone to ensure patient is stable before and after surgery. Thispatient was observed for 1 week in surgical ward, completed 1week course of IV antibiotic. Regular assessment by psychiatryteam was done. Discharged well after 1 week and givenappointment after 2 weeks to psychiatry clinic.
Continuous follow up under psychiatric team and optimization ofmedication is crucial for this patient to prevent further attempt ofsharp object ingestion.
Lessons Learnt & ConclusionThis is rare case of recurrent ingestion of sharp objects following
hallucination and poor insight of illness. Imaging is necessary in such case. Laparatomy is required as objects ingested were sharp and potentially damaging to bowel. Proper psychiatry management is needed in this case to avoid recurrence
References1.Henry K . Ingestion of sharp foreign object:A Case series Literature review
and management recommendation. Journal of gastric disorder and
therapy.2015 1.1, 1-4
2. Gitlin DF1, Caplan JP, Rogers MP, Avni-Barron O, Braun I, Barsky AJ.
Foreign-body ingestion in patients with personality disorders.
Psychosomatics.2007 Mar-Apr;48(2):162-6.
3.Mehran et al(2005) Gastric perforation secondary to ingestion of a sharp
foreign body.Journal of the society of Laparoendoscopic surgeon.2005 9(1)
,91-93
Department of Emergency Medicine and TraumaHospital Kuala Lumpur, Kuala Lumpur 50586 MALAYSIA
