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Successful endoscopic removal of a press-through package in the terminal ileum causing obstructive ileus
At the Focal Point
Successful endoscopic removal of a press-through package in the terminal ileum causing obstructive ileus
A 73-year-old alert man presented to our emergency department with the acute onset of lower abdominal pain. He had no history of abdominal surgery or psychiatric illness. He had been taking some oral medications marketed in a (push) press-through package (PTP) every day for his hypertension and hyperlipidemia. His vital signs were normal. Physical examination revealed hyperactive bowel sounds and lower abdominal tenderness with rebound tenderness. Laboratory tests showed a white blood cell count of 12,800/mm3 (normal 3500-9200 /mm3) and a serum C-reactive protein of 2.2 mg/dL (normal ⬍ 0.3 mg/dL). A plain abdominal film showed only a nonspecific gas pattern with no evidence of free air or foreign body. Abdominal CT demonstrated dilated ileal loops, suggestive of ileus, and a foreign body lodged in the terminal ileum, with wall thickening (A). The foreign body appeared as an oval object surrounded by air, suggestive of www.giejournal.org
a PTP containing a drug tablet. No intraperitoneal free air or abscess was identified. Emergent colonoscopy was performed, which revealed a PTP containing a pill that was stuck in the terminal ileum; this was removed smoothly with a biopsy forceps (B). The patient did not recall that he had accidentally swallowed the PTP. He was completely recovered 4 days after endoscopic removal of the PTP.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Tomoyuki Akiyama, MD, PhD, Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, Kazuro Chiba, MD, Department of Gastroenterology, Tokyo Metropolitan Komagome Hospital, Fumitake Jono, MD, Keiko Akimoto, MD, Volume 75, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 671
At the Focal Point
Ayako Takahata, MD, PhD, Nobutaka Fujisawa, MD, PhD, Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, Tokyo; Masahiko Inamori, MD, PhD, Shin Maeda, MD, PhD, Atsushi Nakajima, MD, PhD, Department of Gastroenterology, Yokohama City University School of Medicine,
Yokohama; Atsushi Nakamura, MD, PhD, Shigeru Koyama, MD, PhD, Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan doi:10.1016/j.gie.2011.11.008
Commentary Accidental ingestion of foreign bodies by adults often occurs in 3 scenarios: (1) elderly individuals with dentures, especially when the patient also has altered mental status; (2) persons who are intoxicated; (3) people working in occupations in which nails, pins, and other objects are held in the mouth during work (carpenter, seamstress/tailor, roofer). It is estimated that 80% to 90% of ingested foreign bodies pass through the GI tract without clinical sequelae and that only 10% to 20% require intervention. Objects larger than 2.5 cm and those longer than 5 cm may not pass the pylorus and negotiate the duodenal sweep, but, in general, once a foreign body negotiates the esophagus and passes into the stomach, patients will be without symptoms unless a complication, for example, perforation or obstruction, occurs. The tablet that this patient inadvertently swallowed was marketed in a blister pack, a term for several types of pre-formed plastic packaging used for small consumer goods, foods, and pharmaceuticals; this particular type of blister pack also is referred to as a push (or press)-through-pack (PTP). Blister packs consist of a pocket usually made from a thermoformed plastic that is backed by a paperboard or lidding of aluminum foil or plastic. The plastic webs usually are formed from thin sheets (250 m) of polyvinyl chloride, polychlorotrifluoroethylene, or cyclic olefin polymers. Regardless of the criteria used to choose one over another, and without regard to moisture and oxygen ingress, chlorine content, or structural rigidity, blister packs are not made to be swallowed. Nietzsche said that “a strong and secure man (today I’m sure he would have said man or woman) digests his experiences just as he digests his meat. . .,” but no one could digest a PTP, regardless of whether foil- or plastic-lidded. Lawrence J. Brandt, MD Associate Editor for Focal Points
Ischemic jejunopathy A 77-year-old woman was transferred to our hospital because of obscure overt GI bleeding characterized by hematochezia. Her medical history was positive only for hypertension, and she admitted to the ingestion of large amounts of ibuprofen to treat headaches. EGD and colonoscopy performed at the referring hospital were unrevealing except for ongoing bleeding and colon diverticulosis. Physical examination on admission revealed pallor, a pulse of 100 beats per minute, and a blood pressure of 90/60 mm Hg. Her abdomen was soft, with increased bowel sounds. The hemoglobin level was 8.9 g/dL (normal 11-14 g/dL), and the prothrombin time was 12 seconds (12-14 seconds). Repeat EGD and colonoscopy disclosed colon diverticula, multiple blood clots in the colon, and fresh blood emanating from the ileocecal valve. Oral double-balloon enteroscopy disclosed a normal-appearing proximal jejunum (A). In the mid-jejunum, the folds appeared as thick cords, with multiple bleeding and nonbleeding linear erosions and ulcers (B, C). Histology showed mucosal ulcerations and hemorrhagic necrosis, with multiple arterial thrombi involving small and large arteries (D, H&E, orig. mag. ⫻400).
672 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 3 : 2012
There were no changes consistent with vasculitis. Laboratory test data were negative for vasculitic markers. CT angiography showed diffuse atherosclerosis but a patent aorta as well as mesenteric and celiac trunk arteries. The ischemic jejunopathy likely resulted from nonsteroidal anti-inflammatory drug ingestion. The patient improved after treatment with intravenous crystalloids, blood transfusions, and oxygen. She has not had further bleeding episodes during a 1-year follow-up period. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Klaus Mönkemüller, MD, PhD, FASGE, Lucia C. Fry, MD, Division of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Department of Internal Medicine, Gastroenterology and Infectious Diseases, Marienhospital Bottrop, Germany doi:10.1016/j.gie.2011.10.034
www.giejournal.org
Successful endoscopic removal of a press-through package in the terminal ileum causing obstructive ileus
A 73-year-old alert man presented to our emergency department with the acute onset of lower abdominal pain. He had no history of abdominal surgery or psychiatric illness. He had been taking some oral medications marketed in a (push) press-through package (PTP) every day for his hypertension and hyperlipidemia. His vital signs were normal. Physical examination revealed hyperactive bowel sounds and lower abdominal tenderness with rebound tenderness. Laboratory tests showed a white blood cell count of 12,800/mm3 (normal 3500-9200 /mm3) and a serum C-reactive protein of 2.2 mg/dL (normal ⬍ 0.3 mg/dL). A plain abdominal film showed only a nonspecific gas pattern with no evidence of free air or foreign body. Abdominal CT demonstrated dilated ileal loops, suggestive of ileus, and a foreign body lodged in the terminal ileum, with wall thickening (A). The foreign body appeared as an oval object surrounded by air, suggestive of www.giejournal.org
a PTP containing a drug tablet. No intraperitoneal free air or abscess was identified. Emergent colonoscopy was performed, which revealed a PTP containing a pill that was stuck in the terminal ileum; this was removed smoothly with a biopsy forceps (B). The patient did not recall that he had accidentally swallowed the PTP. He was completely recovered 4 days after endoscopic removal of the PTP.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Tomoyuki Akiyama, MD, PhD, Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, Kazuro Chiba, MD, Department of Gastroenterology, Tokyo Metropolitan Komagome Hospital, Fumitake Jono, MD, Keiko Akimoto, MD, Volume 75, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 671
At the Focal Point
Ayako Takahata, MD, PhD, Nobutaka Fujisawa, MD, PhD, Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, Tokyo; Masahiko Inamori, MD, PhD, Shin Maeda, MD, PhD, Atsushi Nakajima, MD, PhD, Department of Gastroenterology, Yokohama City University School of Medicine,
Yokohama; Atsushi Nakamura, MD, PhD, Shigeru Koyama, MD, PhD, Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan doi:10.1016/j.gie.2011.11.008
Commentary Accidental ingestion of foreign bodies by adults often occurs in 3 scenarios: (1) elderly individuals with dentures, especially when the patient also has altered mental status; (2) persons who are intoxicated; (3) people working in occupations in which nails, pins, and other objects are held in the mouth during work (carpenter, seamstress/tailor, roofer). It is estimated that 80% to 90% of ingested foreign bodies pass through the GI tract without clinical sequelae and that only 10% to 20% require intervention. Objects larger than 2.5 cm and those longer than 5 cm may not pass the pylorus and negotiate the duodenal sweep, but, in general, once a foreign body negotiates the esophagus and passes into the stomach, patients will be without symptoms unless a complication, for example, perforation or obstruction, occurs. The tablet that this patient inadvertently swallowed was marketed in a blister pack, a term for several types of pre-formed plastic packaging used for small consumer goods, foods, and pharmaceuticals; this particular type of blister pack also is referred to as a push (or press)-through-pack (PTP). Blister packs consist of a pocket usually made from a thermoformed plastic that is backed by a paperboard or lidding of aluminum foil or plastic. The plastic webs usually are formed from thin sheets (250 m) of polyvinyl chloride, polychlorotrifluoroethylene, or cyclic olefin polymers. Regardless of the criteria used to choose one over another, and without regard to moisture and oxygen ingress, chlorine content, or structural rigidity, blister packs are not made to be swallowed. Nietzsche said that “a strong and secure man (today I’m sure he would have said man or woman) digests his experiences just as he digests his meat. . .,” but no one could digest a PTP, regardless of whether foil- or plastic-lidded. Lawrence J. Brandt, MD Associate Editor for Focal Points
Ischemic jejunopathy A 77-year-old woman was transferred to our hospital because of obscure overt GI bleeding characterized by hematochezia. Her medical history was positive only for hypertension, and she admitted to the ingestion of large amounts of ibuprofen to treat headaches. EGD and colonoscopy performed at the referring hospital were unrevealing except for ongoing bleeding and colon diverticulosis. Physical examination on admission revealed pallor, a pulse of 100 beats per minute, and a blood pressure of 90/60 mm Hg. Her abdomen was soft, with increased bowel sounds. The hemoglobin level was 8.9 g/dL (normal 11-14 g/dL), and the prothrombin time was 12 seconds (12-14 seconds). Repeat EGD and colonoscopy disclosed colon diverticula, multiple blood clots in the colon, and fresh blood emanating from the ileocecal valve. Oral double-balloon enteroscopy disclosed a normal-appearing proximal jejunum (A). In the mid-jejunum, the folds appeared as thick cords, with multiple bleeding and nonbleeding linear erosions and ulcers (B, C). Histology showed mucosal ulcerations and hemorrhagic necrosis, with multiple arterial thrombi involving small and large arteries (D, H&E, orig. mag. ⫻400).
672 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 3 : 2012
There were no changes consistent with vasculitis. Laboratory test data were negative for vasculitic markers. CT angiography showed diffuse atherosclerosis but a patent aorta as well as mesenteric and celiac trunk arteries. The ischemic jejunopathy likely resulted from nonsteroidal anti-inflammatory drug ingestion. The patient improved after treatment with intravenous crystalloids, blood transfusions, and oxygen. She has not had further bleeding episodes during a 1-year follow-up period. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Klaus Mönkemüller, MD, PhD, FASGE, Lucia C. Fry, MD, Division of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Department of Internal Medicine, Gastroenterology and Infectious Diseases, Marienhospital Bottrop, Germany doi:10.1016/j.gie.2011.10.034
www.giejournal.org