Endoscopic Management of Multiple Foreign-body Ingestion by Schizophrenic Adult

A 27-year-old male patient of schizophrenia was referred to the gastroenterology department with an alleged history of foreign-body ingestion for 1 day followed by acute-onset dysphagia, associated with hypersalivation. His general physical and systemic examinations were normal. His X-rays revealed a rectangular metallic foreign body in the cervical oesophagus [Figure 1a], three metallic nails in the stomach and three well-defined radio opacities in the pelvis suggestive of stones [Figure 1b]. His whole body non-contrast computed tomography revealed a metallic wire mesh-like foreign body in the cervical oesophagus, three metallic nails in the stomach along with an irregular hyperdense object and a stone-like foreign body in the rectum [Figure 2a and b]. There was no evidence of perforation, pneumomediastinum, pneumoperitoneum and surgical emphysema. His cap-assisted oesophagogastroduodenoscopy was performed under conscious sedation and a metallic wire mesh was retrieved from the cervical oesophagus with foreign body forceps [Figure 3a]. Three iron nails were removed from the stomach with the help of a snare [Figure 3b]. A large stone and a square spectacle glass were removed from the stomach using a Roth Net basket [Figure 3c and d]. There were no procedure-related complications except superficial ulcers in the cervical oesophagus at the site of wire mesh impaction. A nasogastric tube was placed in the stomach and polyethylene glycol bowel preparation was given for colonoscopy to remove rectal stones. The patient gave a history of passage of stones with stool after bowel preparation. A repeat abdominal X-ray did not reveal any stone in the pelvis, so the colonoscopy was different. The patient was referred back to the psychiatry department for further management of schizophrenia. Psychiatric patients are at an increased risk of foreign-body ingestion, many of these patients present with ingestion of multiple foreign bodies and often multiple times with recurrent ingestions.[1] The foreign bodies in the gastrointestinal tract are associated with numerous complications including bleeding, perforation, mediastinitis, subcutaneous emphysema, bowel obstruction, aspiration, abscess formation and fistula formation.[2] Flexible endoscopy is helpful in diagnosing and removing foreign bodies with a success rate of >95%.[3]Figure 1: (a) X-ray neck lateral view image showing metallic rectangular foreign body (blue arrow) in the upper oesophagus, (b) upright X-ray abdomen image showing metallic nails (blue arrow) in the stomach at least three in number and three well-defined radio opacities (red arrow) in pelvis suggestive of stones in the rectum or sigmoid colonFigure 2: (a and b) Sagittal and coronal reconstructed non-contrast computed tomography images - showing rectangular metallic foreign body with artefacts in cervical oesophagus (blue arrow), three metallic nails in the stomach (red arrow) with artefacts and rounded hyperdense structure in rectum suggestive of stone (yellow arrow)Figure 3: (a) Endoscopic image showing cap and foreign body forceps assisted removal of the metallic wire mesh foreign body (blue arrow) from the cervical oesophagus, (b) Endoscopic image showing cap and snare assisted removal of the metallic nails (blue arrow) from the stomach, (c) Endoscopic image showing stone (blue arrow) and square smooth edged spectacle glass (red arrow) in the stomach, (d) Endoscopic image showing Roth Net retrieval basket assisted removal of stone (blue arrow) from the stomachDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.