Ingestion of computer circuit boards causing esophageal impaction and small bowel obstruction Nizar H. Senussi, MD, and Nasir Saleem, MD
a
b
Foreign body ingestion is common in patients with psychiatric diagnoses. Ingested objects can become impacted in the upper and lower gastrointestinal tract, causing serious complications. We report a case of a schizophrenic who ingested large pieces of computer circuit boards, which impacted at the mid-esophagus, in the stomach, and in the cecum. Endoscopic removal of the esophageal object Figure 1. Initial x-ray plain film of esophageal, gastric, and cecal foreign bodies. (a) Chest radiograph showing a 2.5 × 2.5 cm was unsuccessful, and the for- object in the esophagus at the level of the carina. (b) Abdominal x-ray showing a 4 × 4 cm object in the stomach and a eign objects were removed by 2 × 2.3 cm object in the area overlying the small bowel. esophagotomy and laparotomy. Expeditious removal through endoscopic or surgical means is extremely level of the carina (Figure 1a) and two radio-opaque foreign bodies measuring 4 × 4 cm and 2 × 2.3 cm in the stomach and important, as complications can be life-threatening. This is the first report cecum (Figure 1b). A noncontrast computed tomography (CT) of ingestion of a computer printed circuit board.
W
e report a case of the deliberate ingestion of fragments of a computer printed circuit board (PCB) leading to esophageal impaction of one fragment and multiple retained gastric and colonic fragments. This posed a risk for esophageal, gastric, and large bowel perforation and exposed the patient to complications unique to computer PCBs. CASE DESCRIPTION A 48-year-old man with schizophrenia was transferred to the emergency department from a skilled nursing facility after chewing and swallowing a circuit board from a personal computer 4 days earlier. At presentation, he reported only mild substernal chest pain and had been tolerating oral intake over the past several days. His vital signs were stable. He had normal breath sounds bilaterally, no crepitus, and a nontender abdomen. His affect was depressed, and there was no evidence of drug intoxication. Laboratory tests revealed a leukocytosis of 16,000/mm3. Chest and abdominal plain films showed a 2.5 × 2.5 cm metallic object impacted in the esophagus at the
Proc (Bayl Univ Med Cent) 2017;30(1):85–87
scan of the chest, abdomen, and pelvis confirmed the presence of multiple foreign bodies and showed no evidence of mediastinitis or bowel perforation. Emergent endoscopy to remove the esophageal object was unsuccessful. The object was flat shaped and embedded in the esophageal wall (Figure 2). A nasogastric tube was placed at the time of endoscopy in anticipation of postoperative needs. The patient was taken for right thoracotomy, esophagotomy, and removal of the foreign body with primary esophageal closure with intercostal muscle flap. At operation, the esophageal wall was thickened but no perforation was seen, and the foreign body was removed from the esophagus. The following day, the patient underwent exploratory laparotomy for removal of the gastric and cecal metallic bodies as well as several plastic pieces via gastrotomy and colotomy (Figure 3). Fluoroscopic localization From Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio (Senussi), and Department of Internal Medicine, Presence Saint Joseph Hospital, Chicago, Illinois (Saleem). Corresponding author: Nizar Senussi, MD, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue/A51, Cleveland, OH 44159 (e-mail:
[email protected],
[email protected]; Twitter handle: nsenussiMD). 85
h
and delirium, which were treated with antipsychotics. A follow-up chest x-ray 25 days after the operation showed resolution of empyema. A repeat esophagram at 29 days showed no leak. The patient was discharged to a nursing home 53 days after admission. DISCUSSION Foreign body ingestion Figure 2. Endoscopy revealing an impacted esophageal foreign object with a green surface, metallic components, and edges is the emergent consequence firmly embedded in the esophageal walls. Retrieval was unsuccessful due to the risk of inducing esophageal perforation, and of a unique constellation the patient was scheduled for surgery. of behaviors and patterns in adults and children. As many as 1500 people die in the United States each year as a for the retained colonic fragments was used, and a feeding jeresult of foreign body ingestion (1). In adults, risk factors for junostomy tube was also placed. ingestion include accidental swallowing of bones, dental surgery, The postoperative course was complicated by respiratory visual impairment, and bulimia nervosa (2). However, a portion failure requiring continued ventilator support for 6 days. A postof ingestions in adults are deliberate, with about 85% of these operative contrast esophagram showed contrast extravasation at patients having a prior psychiatric diagnosis and 84% of patients the esophagotomy site. It was managed with antibiotics and conhaving had prior ingestions. Thus, deliberate foreign body ingestinued chest tube drainage. Seven days after the operation, CT tion can have a significant health and economic impact. While of the chest showed fluid and gas collections in the paraesophamost ingested objects will pass per rectum spontaneously, 10% geal and right lower hemithorax that were not being drained by to 20% of cases require endoscopic removal, and about 1% the chest tubes. Thoracentesis confirmed empyema with pleural require surgery (3). The risk for gastrointestinal perforation is fluid growing Actinomyces meyeri and Streptococcus mitis. Antibigreater with sharp objects and ranges from 15% to 35% (4, 5). otics were switched to piperacillin-tazobactam and fluconazole Other complications include bowel ischemia, fistulization, and and given for 14 days. The patient also developed agitation metal toxicity from coin ingestion (6). Our case describes the deliberate ingestion of fragments of a computer circuit board with sharp edges. The patient was able to tolerate oral intake in the intervening 4 days before presenting to the hospital. He developed a complicated postoperative course with paraesophageal empyema requiring a prolonged course of antibiotics. We found no comparable studies of delayed esophageal repair for impacted foreign bodies. However, in the case of spontaneous esophageal rupture, one report showed no significant increase in mortality with delayed esophageal repair (7). Computer PCBs are planar, high-hardness, epoxy- and fiberglass-bound boards. While items past the ileocecal valve are generally expected to pass spontaneously, fractured PCBs have the potential to create splintered points and sharp edges. This increases the risk of colonic perforation with spontaneous passage, and therefore surgical extraction was indicated to reduce this risk. Computer boards may also carry on-board batteries. The distal fragments had an appearance that was thought to possibly contain batteries, and this contributed to the rationale for surgical removal. Furthermore, PCBs are frequently plated with copper and lead solder. The possibility of acute lead poisoning was raised, but this was felt to be an insignificant risk and not Figure 3. The patient underwent laparotomy with gastrotomy and colotomy to a contributor to the patient’s clinical scenario. Nonetheless, remove multiple metallic and plastic foreign bodies. Fluoroscopic guidance was this may warrant further investigation in computer hardware used to locate the cecal fragments. The gastrotomy and colostomy sites were ingestions that are treated nonoperatively. closed primarily and a jejunostomy tube was placed intraoperatively. 86
Baylor University Medical Center Proceedings
Volume 30, Number 1
1. 2.
3.
4.
Bloom RR, Nakano PH, Gray SW, Skandalakis JE. Foreign bodies of the gastrointestinal tract. Am Surg 1986;52(11):618–621. Poynter BA, Hunter JJ, Coverdale JH, Kempinsky CA. Hard to swallow: a systematic review of deliberate foreign body ingestion. Gen Hosp Psychiatry 2011;33(5):518–524. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Mallery JS, Raddawi HM, Vargo JJ 2nd, Waring JP, Fanelli RD, Wheeler-Harbough J; American Society for Gastrointestinal Endoscopy. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55(7):802–806. Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995;41(1):39–51.
January 2017
5.
6.
7.
Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, BenMenachem T, Decker GA, Fanelli RD, Fisher LR, Fukami N, Harrison ME, Jain R, Khan KM, Krinsky ML, Maple JT, Sharaf R, Strohmeyer L, Dominitz JA; ASGE Standards of Practice Committee. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011;73(6): 1085–1091. Sugawa C, Ono H, Taleb M, Lucas CE. Endoscopic management of foreign bodies in the upper gastrointestinal tract: a review. World J Gastrointest Endosc 2014;6(10):475–481. Jougon J, McBride T, Delcambre F, Minniti A, Velly JF. Primary esophageal repair for Boerhaave’s syndrome whatever the free interval between perforation and treatment. Eur J Cardiothorac Surg 2004;25(4):475–479.
Ingestion of computer circuit boards causing esophageal impaction and small bowel obstruction
87
