Recurrent Metallic Foreign-Body Ingestion in a Patient with Partial Deletion of Chromosome 15 and Impulse Control Disorder

Abstract

Purpose: Deliberate ingestion of foreign-bodies presents a unique challenge to physicians. It carries a sense of insidiousness for the patient with lack of external evidence of harm but a latent risk of further injury. Methods: A 35 year old Caucasian male presented with history of multiple episodes of swallowing sharp metallic foreign objects, typically paper clips. During all his presentations, there was a frank acknowledgement of ingestion with denial of any suicidal intent. His swallowing behavior had begun at the age of 29 and had resulted in forty hospitalizations for endoscopic procedures and surgeries for foreign body removal. Past history was significant for birth by emergent C-section and reported oxygen deprivation at birth, partial deletion of chromosome 15, mild mental retardation, delayed developmental milestones and behavioral problems with multiple psychiatric hospitalizations since age nine, impulse control disorder, alcohol abuse, pseudoseizures, and long history of self-injurious or parasuicidal behavior. With multiple episodes of foreign-body ingestion, it became difficult to retrieve the foreign-body endoscopically due to distortion of the gastroduodenal anatomy from prior adhesions and strictures related to multiple surgeries. In some instances, the endoscopic removal was deemed unsafe due to either impaction of the sharp foreign bodies or their advancement beyond the duodenum sweep resulting in need for open laparotomy. He was extremely resistant to psychiatric treatment or follow-up after these hospitalizations. Results: Ingestion of foreign objects is common in children, prison inmates, and those with psychiatric history or mental retardation. Majority of gastrointestinal foreign-bodies pass spontaneously. Sharp or pointed objects perforate the gastrointestinal wall in 15-35% cases, thus requiring endoscopic or surgical removal. Our patient with history of partial deletion of chromosome 15 (associated with mental retardation and behavioral problems) and oxygen deprivation at birth placed him at unique risk of impulse control disorder consequently resulting in a repetitive behavior of self-harm manifested as foreign-body ingestion. This type of self-injurious behavior is usually repetitive, non-suicidal, reported typically in women below age 30, and in patients with history of childhood abuse or neglect. Dialectical behavioral therapy, Naltreoxone and Clonidine have shown to have some benefit in preventing such behavior. Conclusion: Recurrent foreign-body ingestion is an uncommon but devastating presentation of patients with severe personality disorders. Its association in patients with partial deletion of chromosome 15 and impulse control disorder presents a unique perspective to this case.