Iron Toxicity

Sharp Object Ingestion by Schizophrenic Patient

Department of Emergency Medicine and Trauma
Hospital Kuala Lumpur, Kuala Lumpur 50586 MALAYSIA
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.

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.

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.

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