Deliberate ingestion of stones causing a diagnostic dilemma. A personal experience

Abstract

Deliberate ingestion of foreign bodies is not a new subject especially in our society where such patients are neglected and their problems are rarely investigated properly. These kinds of problems usually have a compulsive driven and complicated elements involved which are very refractory to treatment and are often repetitive. Such a habit is mostly seen in children of very tender age but the situation is more worrisome when you come across adults who are otherwise considered normal but are found to have a deliberate compulsion to ingest funny things like papers, stones, jewelry and other injurious agents which can lead to life threatening complications. A very interesting case of a young girl is presented here which will certainly be beneficial to the surgeons as well as practitioners.

Introduction

Deliberate and repetitive ingestion of different kinds of foreign bodies is a common and a global problem. ^(1–2) Such foreign bodies are usually food products or a piece of bone and are easily recovered but about 1% need surgical intervention. Such deliberate ingestions of foreign bodies are rare in conscious and healthy people but are frequently seen in psychiatric, insane and retarded adults. ⁽⁴⁾ Most of the intentional and repeated swallowing has a psychiatric background which had not been given much attention in the past. ⁽⁵⁾ There may be an element of seeking attention or escaping responsibilities in such subjects but most of the studies have suggested that the subjects are usually mentally retarded and have significantly low IQ.

Case Report

An 18 years old, unmarried girl presented in my hospital OPD with complaints of lower urinary tract symptoms like pain in abdomen, burning micturation, urinary frequency and generalized weakness. There was history of taking some antibiotics and antipyretics prescribed by a local physician. On examination the girl was of average built with mild anemia and a bit slow in her response to questions. She was also showing reluctance for further enquiry into her problem. Otherwise the examination was unremarkable. She was admitted and her routine blood and urine tests were done as well as a plain X-ray abdomen and Ultrasound. The ultrasound showed 3 stones each of 2–3cm in the right renal area while the x-ray confirmed 3 stones in the right renal area. I was convinced to some extent but her urine reports were absolutely normal in contrast to her symptoms. The next morning I again requested for a fresh X-ray of the abdomen which gave me a little shock. This time there were 5 stones instead of 3 and they were in different positions in the abdomen. Next morning another X-ray performed and now there were 6 stones in the upper GIT and in epigastric area. Finally without her knowledge we attached one house keeper to keep a strict watch on the girl and see what she is doing in the ward. To my surprise, after about two days struggle, the female house keeper could actually see her from a hidden window of washroom that she was passing stones in stool on the ground and the re-ingesting the same with few more if she finds nearby. It was then re-confirmed by two other lady doctors in the same manner and we finally got our confusion solved. The mother of the patient was briefed about her condition and she was referred to a psychiatrist.

Discussion

Although a rare problem in mentally alert and healthy adults, foreign body ingestion is common among psychiatric and mentally retarded people and especially in the hospitalized patients. ⁽⁶⁾ The management of such patients is not only time taking but also a financial burden and a psychological trauma to the whole family. ⁽⁷⁾ This is consistent with our case report where patient remained hospitalized for about a week. Behavioral and intellectual disabilities are usually common as in the patient reported in this study. The management of such patient involves a multidisciplinary team including a psychiatrist. ⁽⁸⁾ The tragic aspect of this problem is that most of such reports are published in surgery or other specialties but not in psychiatric and most of the studies focus on the techniques of management, intervention and complications following ingestion of injurious objects. There is no concern over the underlying psychiatric disorder or its pathophysiology. We strongly suggest that such patients should be given full attention by constituting a team comprising different specialties. The role of a psychiatrist is pivotal as they can explore the underlying problem and the actual intention of repeated ingestion of foreign bodies.

Conclusion

Repeated ingestion of foreign bodies is a common problem in psychiatric and mentally disabled patients. These patients need to be diagnosed and should be referred to psychiatrists to establish the actual underlying disorder. The ultimate management involves a multidisciplinary team.