Hereʼs Looking at You Kid: A Case of Repeated Doll Head Ingestion: An Endoscopic Challenge ACG Case Reports Journal Award Presidential Poster

Abstract

A 57-year-old man with 40-year-history of doll fetishism and swallowing doll heads for erotic pleasure presented with three days of worsening abdominal pain. His history is significant for two prior exploratory laparotomies for small bowel obstruction caused by doll head ingestion. CT abdomen and pelvis showed a small bowel obstruction with transition point in the terminal ileum and a dilated stomach with 5 curvilinear foreign bodies in the antrum. Because the patient failed nasogastric decompression over 6 days, esophagogastroduodenoscopy was performed to rule out concurrent gastric outlet obstruction by foreign bodies. This revealed 1 liter of foul, retained gastric fluid, a 6mm clean based ulcer at the incisura, and 5 doll heads in the gastric body and fundus, one of which was wrapped in a knotted green plastic bag. The heads were able to be retained by snare, but were unable to be extracted through the esophagogastric junction due to size. The patient underwent exploratory laparotomy, lysis of adhesions, and reduction of an internal hernia at the terminal ileum. Two additional doll heads were palpated in the small bowel and subsequently expressed into the colon. Gastrotomy was performed to remove 5 tan to brown male doll heads ranging in size from 4.3 x 3.5 x 2.8 cm to 6.0 x 3.3 x 2.6 cm. The patient underwent an uneventful post-operative recovery. This is the first case report of repeated doll head ingestion in the literature. Most foreign objects, after having passed through the esophagus, will pass without need for intervention in about 4-6 days. Endoscopic interventions may be needed in 63-76% of cases, especially when there is esophageal obstruction, or ingestion of sharp objects or magnets which can lead to perforation. Objects larger than 2.5 cm should be removed because they are less likely to pass through the pylorus. Objects that fail to pass beyond the stomach by 3-4 weeks should also be removed. Surgical interventions are needed in 12-16% of cases, and are required in small bowel obstructions, peritonitis, ingestion of narcotic packets, or when endoscopic interventions fail. The prevalence of pica is unknown, but may be more common in those with psychiatric disorders in the Western world, and associated with malnutrition or behavioral rituals in other parts of the world. Literature search revealed at least 3 case reports of foreign body ingestion associated with gastric ulcer. One review cited 43 cases of surgical complications by various forms of pica. Intestinal obstruction was the most common clinical presentation and the ileum was the most common site of obstruction reported at surgery.Figure 1Figure 2Figure 3