Non-Surgical Management of an Embedded Sharp Paper Clip in the Sigmoid Colon Causing Perforation and Abscess: A Case Report

Abstract

Introduction Ingested sharp foreign bodies (FB) can be associated with complications and surgical treatment is considered mandatory once complications such as abscess and perforation develop. We report a case of a pelvic abscess related to an ingested FB managed non-surgically. Case Presentation A 42 yr old male prisoner presented with complaints of abdominal pain. He has had history of multiple FB ingestions needing endoscopic removal. At presentation, vital signs were normal; abdominal exam revealed tender LLQ without peritoneal signs; labs were unremarkable except for WBC count of 12.7 k/μL. CT revealed a perforated sigmoid colon due to a linear metallic FB or two adjacent FBs and an associated 3.5 cm abscess [Fig. 1]. Patient reported ingesting a paperclip several months back. As the patient was hemodynamically stable and without peritoneal signs, decision was made by a multidisciplinary team to attempt endoscopic retrieval of the embedded FB. A transrectal 10F pigtail drain was placed by IR to drain the pelvic abscess. Under GA and fluoroscopy support, flexible sigmoidoscopy was performed. At 25 cms from the anal verge, an embedded metal clip with two exit points into the lumen, adjacent to each other was noted [Fig. 2]. Fluoroscopy images showed the paperclip had bent into a U shape with the round end inside the abscess cavity and the two sharp ends protruding into the colon lumen [Fig. 3]. Several initial attempts at removing the metal paperclip using snare and raptor forceps failed. Finally, using a rat tooth forceps, the distal sharp end of the paperclip was grasped and under fluoroscopic guidance the paper clip was removed requiring significant tension. Re-examination with cap assisted endoscopy showed no obvious perforation. Fluoroscopy did not show any free air. Patient had an uneventful hospital course and was discharged two days later on oral antibiotics. He has continued to do well and the JP drain was removed four weeks later after resolution of abscess.Discussion FB ingestions in adults is mostly intentional. About 10 to 20% require endoscopic intervention and 1% or less requires surgical intervention. In our case, the ingested elongated metallic paperclip had lodged in the sigmoid colon causing perforation and abscess. Despite this, we proceeded with minimally invasive interventions with successful endoscopic removal of the clip and drainage of abscess, avoiding surgery.1518_A Figure 1. Computerized tomography showing embedded foreign body in the sigmoid colon and abscess.1518_B Figure 2. Endoscopic view of the foreign body lodged in the sigmoid colon.1518_C Figure 3. Fluoroscopy image of the foreign body prior to its retrieval.