Doctors Retrieved Nails From Patient’s Bowels

While most cases of foreign body retrieval involve the upper gastrointestinal tract (GI), a young woman needed a colonoscopy after she intentionally swallowed multiple nails, researchers reported.

For a woman in her 30s who was under psychiatric care and had a history of swallowing foreign bodies, the nails lodged in the ileocecal valve between the small and large intestines, Bhoowit Lerttiendamrong, MD, from the University of Connecticut School of Medicine in Farmington, told MedPage Today.

The medical team elected to remove the nails with colonoscopy, using a hard, transparent cap attached to the distal end of the scope to protect the mucosal lining.

“Using this technique, the nails were successfully removed with only minimal mucosal trauma to the colon,” Lerttiendamrong and colleagues reported in BMJ Case Reports. “This case supports the use of a cap to minimize colonic mucosal injury during sharp foreign body removal in the colon.”

“It’s pretty rare to have a foreign body that goes all the way down to the lower GI system, and even rarer that sharp foreign bodies go down that far,” Lerttiendamrong said in an interview. “There’s still some limitation, because it’s not a widely proven procedure, but there’s no actual guideline on how to deal with these sorts of cases.”

Intentional swallowing of foreign bodies is seen in patients with advanced age, intoxication, developmental delays, incarceration, or as in this case, psychiatric disorder, the authors wrote. While about 80% of ingested foreign bodies are passed spontaneously, endoscopic retrieval should be considered for patients who don’t respond to conservative management, or in cases involving sharp objects that increase risk for perforation, they noted.

“Nails are especially difficult to remove endoscopically due to their sharp, irregular shapes, which can make them hard to grasp and may require surgical intervention.”

In cap-assisted endoscopy, a short polymer tube is attached to the distal tip of the endoscope to minimize blind spots during screening colonoscopy, prevent mucosal injuries, and provide an accurate assessment of the lesion size. Only a few reports have described removal of foreign bodies from the lower GI tract, in this case using cap-assisted colonoscopy.

The patient had a history of intentional foreign body ingestion, pica disorder, and anxiety disorder, the authors wrote. She presented with persistent abdominal pain after swallowing multiple nails, her sixth episode of ingesting foreign bodies in the last year.

She was initially managed conservatively, with serial abdominal radiographs every 12 hours, bowel rest, and 3 liters of polyethylene glycol therapy. The nails were considered to be too far along for safe endoscopic removal.

Repeat imaging showed the nails moved from the mid-abdomen to the right lower quadrant, “ultimately clustering near the ileocecal valve,” they said. After 4 days with no spontaneous passage, they undertook to remove the nails using cap-assisted colonoscopy.

All eight nails were successfully removed using a snare, “with care taken to secure the sharp ends beneath the cap,” they noted. Inspection of the mucosa after the procedure showed “only minor superficial abrasions.”

The psychiatry department was consulted on her case, but despite their recommendation that she be admitted, she “adamantly” refused, they wrote. One year later, there have been no further complications after the colonoscopy, and the patient is being followed on an outpatient basis.

Although cap-assisted colonoscopy was successfully used in this case, several technical limitations were identified. For example, advancing the colonoscope with a cap can be “challenging,” particularly in a tortuous or difficult colon, and while the cap protects mucosa from the foreign object, it may cause trauma itself.

Despite these limitations, “this case demonstrates that cap-assisted colonoscopy can be a useful and safe tool for the removal of sharp foreign objects from the colon in clinically stable patients without evidence of perforation or peritonitis, provided that surgical backup is readily available,” the authors concluded. “This technique should be performed only by experienced endoscopists, as the risk of perforation is significant both before and during the procedure.”