Harleen Chela, MBBS, MD, Michael Dahip, MD, Omer Basar, MD, Veysel Tahan, MD, FACG, Ebubekir Daglilar, MD; University of Missouri, Columbia, MO
Introduction: Foreign body ingestion is a common scenario that is encountered by gastroenterologist. We describe a rare case of ingestion of a wrench in a patient with history of psychiatric illness.
Methods: 25-year-old male with depression presented to hospital with hematemesis and reported swallowing nails, screws, and a wrench. On exam, he was febrile (39°C), tachycardic, normotensive with tender abdomen. Labs showed anemia (hemoglobin 7.6 gm/dl), INR of 1.2, and lactic acidosis. X-ray chest/abdomen showed a metallic wrench (20 x 3.8 cm) in lower esophagus/proximal stomach with smaller objects in epigastric/pelvic region. CT scan of abdomen and pelvis confirmed the findings and no perforation seen. Upper endoscopy was performed in the OR following endotracheal intubation with surgery team as backup which showed a wrench stuck in distal esophagus and tip extending to stomach body. Superficial tears were seen in distal esophagus and stomach noted to have large amount of clots/blood products which could not completely suctioned. A 20 mm snare was used to grab the wrench and passage from oropharynx facilitated with McGill forceps. High dose acid suppression therapy was initiated. Repeat endoscopy performed for ongoing hematemesis which revealed large gastric ulcer with densely adherent clot, active spurting was seen following removal of the clot from ulcer base. Conventional endoscopic methods failed to achieve hemostasis. Interventional radiology consulted and selective celiac artery angiography showed large splenic artery pseudo-aneurysm and active extravasation from the artery. Coil embolization of splenic artery was performed with successful hemostasis. Psychiatry team advised neuropsychiatric testing for intellectual disability. Patient was discharged with outpatient treatment plan. Discussion: Foreign body ingestion is more common in pediatric population and when it occurs in adults it’s often associated with psychiatric illness or intellectual disability, alcohol intoxication or secondary gain in those who are incarcerated. Our patient had recurrent foreign body ingestions with concern for underlying intellectual delay and psychiatric disorder. The object ingested was relatively large and resulted in gastrointestinal bleeding due to likely pressure related gastric ulcer and pseudo-aneurysm formation. This case has been a rare occurrence of a successful endoscopic removal of a large metal wrench.
X-ray chest and abdomen showing the radiopaque wrench in the esophagus and extending to the stomach (note other metallic objects).
CT scan abdomen and pelvis showing the wrench in the lower portion of the esophagus and the proximal stomach.
Upper endoscopy revealing the wrench in the esophagus and successful retrieval.
Disclosures: Harleen Chela indicated no relevant financial relationships. Michael Dahip indicated no relevant financial relationships. Omer Basar indicated no relevant financial relationships. Veysel Tahan indicated no relevant financial relationships. Ebubekir Daglilar indicated no relevant financial relationships.