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CASE REPORT
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 118-120

Spontaneous Partial Percutaneous Extrusion of Swallowed Metallic long Spoon: A Case Report


Department of Surgery, Imo State University Teaching Hospital, Orlu, Imo State, Nigeria

Date of Submission18-Aug-2020
Date of Acceptance30-Aug-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Dr. C N Ekwunife
Department of Surgery, Imo State University Teaching Hospital, Orlu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_512_20

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   Abstract 


Foreign body ingestion is a commonly encountered clinical challenge. Most of these objects pass spontaneously, but long objects could be retained leading to uncommon complications. There seem to be no record of percutaneous extrusion of ingested spoon in literature. We report a case of 20 year old lady who swallowed a long metallic spoon. It got retained in the stomach for a month without obstructive symptoms, until the tail end of it eroded onto the skin. It was retrieved through an open gastrotomy. Patient had an uneventful postoperative recovery. Clinicians should be mindful that ingested large foreign bodies may be delayed in presentation. Whereas our index patient had open surgery, minimally invasive retrieval approaches could be considered when comparable cases are encountered.

Keywords: Foreign body, gastrotomy, ingestion, percutaneous, stomach perforation


How to cite this article:
Ekwunife C N, Ogbue U N, Kaduru C O. Spontaneous Partial Percutaneous Extrusion of Swallowed Metallic long Spoon: A Case Report. Niger J Clin Pract 2022;25:118-20

How to cite this URL:
Ekwunife C N, Ogbue U N, Kaduru C O. Spontaneous Partial Percutaneous Extrusion of Swallowed Metallic long Spoon: A Case Report. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 3];25:118-20. Available from: https://www.njcponline.com/text.asp?2022/25/1/118/335986




   Introduction Top


Accidental or intentional ingestion of a foreign body is a frequently encountered clinical problem. While all age groups may be affected, it is much commoner in pediatric patients. Among adults, affected high-risk groups are those with psychiatric disorders, developmental delay, alcohol intoxication, prisoners, and those who wear dentures.[1],[2] Where a foreign body negotiates the natural constrictions of the pharynx and esophagus, it is likely to pass through the gastrointestinal tract in 80% of cases. Among the remaining 20% that may cause complications, only about 1% will cause gastrointestinal perforation.[3],[4],[5] We report a case of delayed presentation of a spoon with long handle held up in the stomach. To the best of our knowledge, there has not been any previous report of partial extrusion of this type of foreign body through the skin.


   Case Presentation Top


An unmarried 20-year-old postsecondary school female presented to the Accident and Emergency Department with a one-day history of a metallic object protruding from the epigastric region. Two days prior to this, her caregivers noticed a “boil” on the same area. There was no associated vomiting, fever, dysphagia, or hematochezia. She admitted to having swallowed a metallic spoon a month prior to this period. There was a 2-year preceding history of irrational speech, mood disorder, auditory and visual hallucination which started postpartum. A past history of self-inflicted burn injury to the anterior chest wall was also elicited. She was clinically stable with a pulse rate of 90 and blood pressure of 120/79 mmHg. The tip of the spoon was seen projecting from the epigastrium [Figure 1] with adjoining mild tenderness. A diagnosis of gastrocutaneous fistula was made. Her hemoglobin was 11.3 g/dL, white blood cell count 4600/mm3 and K+ 4.0 mmol/L. She was subsequently worked up for laparotomy. Intraoperatively the stomach was found adherent to the anterior abdominal wall. There was a 2 × 3 cm perforation of the anterior wall of the fundus by an 18 cm long metallic spoon with no peritoneal soilage [Figure 2] and [Figure 3]. It was extracted and primary repair of the stomach done. Patient had an uneventful postoperative discovery. She was discharged on the 10th postoperative day and is now being followed up at the Psychiatric clinic.
Figure 1: Preoperative

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Figure 2: Intraoperative 1

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Figure 3: Intraoperative 2

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   Discussion Top


Foreign body ingestion in psychiatric patients throw up some peculiar diagnostic and management challenges. They are mostly schizophrenics who may swallow relatively large inorganic objects on multiple occasions, may delay in presenting to the hospital, and whose immediate postoperative management may be difficult.[6] The 18 cm length of the spoon makes it unlikely that the spoon would have been swallowed accidentally. And it is all the more remarkable that the spoon could pass through the esophagus without entrapment. It is probable that where the handle of the spoon is the leading end being swallowed, the chance of retention within the esophagus may be higher.

Although 80-90% of foreign bodies that get to stomach are eventually passed out, spontaneous passage of a spoon is very unlikely.[7] In our index case, it was retained in the stomach for one month. Long handle spoons that are more than 6 cm are unlikely to exit the stomach and those less than 6 cm may be held up at the ileocecal valve.[4] On rare occasions, however, longer spoons have travelled to the jejunum and ascending colon.[7],[8]

The unique feature of this report is that the spoon fistulated onto the skin without accompanying generalized peritonitis. This finding aligns with previous reports that chronic perforation and walled-off abscess formation seem more likely in the stomach and colon.[9] These patients may therefore present an indolent and innocuous picture, whereas perforation in the ileum and jejunum presents more acutely with generalized peritonitis.

Varied approaches to the extraction of the spoon lodged in the stomach have become available. These include endoscopy, open and laparoscopic surgery. Although the open surgical approach is quite safe and relatively straightforward, this approach is no longer invariable. We employed open surgery as the first option partly because the appropriate endoscopic accessories were not readily available in the hospital when the patient presented. While there is a risk of esophageal perforation, a 14-cm spoon which has passed entirely through the pylorus has been successfully retrieved at upper gastrointestinal endoscopy.[10] The fact that the gastrocutaneous fistula has been walled-off from the peritoneal cavity implies that the risk of peritonitis after endoscopic extraction will be virtually nonexistent. This will obviate the potential postoperative difficulties in nursing a psychiatric patient. Laparoscopic extraction would also be less traumatic for the patient as similar long objects like fork has been so retrieved.[11]


   Conclusion Top


An ingested large foreign body like a spoon that has passed into the stomach may be delayed in presentation. Since it is unlikely going to be passed spontaneously, early retrieval will avoid complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011;73:1085-91.  Back to cited text no. 1
    
2.
Obinwa O, Cooper D, O'Riordan JM, Neary P. Gastrointestinal foreign bodies. In: Garbuzenko D, editor. Actual Problems of Emergency Abdominal Surgery. Croatia: InTech; 2016. p. 77-94.  Back to cited text no. 2
    
3.
Selivanov V, Sheldon GF, Cello JP, Crass RA. Management of foreign body ingestion Ann Surg 1984;199:187-9.  Back to cited text no. 3
    
4.
Velitchkov AG, Grigorov GI, Losanoff JE. Ingested foreign bodies of the gastrointestinal tract: Retrospective analysis of 542 cases. World J Surg 1996;20:1001-5.  Back to cited text no. 4
    
5.
Odeghe E, Osueni A, Owoseni OO, Adeniyi F, Lesi O. Upper gastrointestinal bleeding secondary to an incidental, impacted foreign body in the duodenum. Cureus 2020;12:e6971.  Back to cited text no. 5
    
6.
Barros JL, Caballero A Jr, Rueda JC, Monturiol JM. Foreign body ingestion: Management of 167 cases. World J Surg 1991;15:783-8.  Back to cited text no. 6
    
7.
Deeba S, Purkayastha S. Surgical removal of a teaspoon from the ascending colon, ten years after ingestion: A case report. Cases J 2009;2:7532.  Back to cited text no. 7
    
8.
Song Y, Guo H, Wu JY. Travel of a mis-swallowed long spoon to the jejunum. World J Gastroenterol 2009;15:4984-5.  Back to cited text no. 8
    
9.
Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006;30:372-7.  Back to cited text no. 9
    
10.
Shen CS, Su YC. Endoscopic retrieval of mis-swallowed table spoon. Case Rep Gastroenterol 2019;13:32-6.  Back to cited text no. 10
    
11.
Schenk C, Mugomba G, Dabidian RA, Scheuerecker H, Glaser F. Laparoscopic extraction of a swallowed fork in a patient first diagnosed with bulimia nervosa. Surg Endosc 2002;16:361.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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    Abstract
   Introduction
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   Discussion
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