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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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Year : 2017  |  Volume : 22  |  Issue : 3  |  Page : 179-180

A sharp lesson: Duodenal perforation 2 months after ingestionof a pin

1 Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, G51 4TF, UK
2 Department of Emergency, Birmingham Children's Hospital, Birmingham, B4 6NH, UK
3 Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, B4 6NH, UK

Date of Web Publication8-Jun-2017

Correspondence Address:
Rebecca Amy Dalrymple
Ward 3C, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.JIAPS_250_16

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An 11-year-old female child presented 2 months after accidentally swallowing her hijab pin, with right-sided abdominal pain. An X-ray showed that the pin was located in her right upper quadrant, and at laparoscopy, it was found to have eroded through her duodenum into her liver. Ingested pins should always be removed if not passed spontaneously within the first few days.

Keywords: Abdominal pain, foreign body, ingestion, pediatric surgery, perforation, pin

How to cite this article:
Dalrymple RA, Berry K, Jester I. A sharp lesson: Duodenal perforation 2 months after ingestionof a pin. J Indian Assoc Pediatr Surg 2017;22:179-80

How to cite this URL:
Dalrymple RA, Berry K, Jester I. A sharp lesson: Duodenal perforation 2 months after ingestionof a pin. J Indian Assoc Pediatr Surg [serial online] 2017 [cited 2020 Sep 26];22:179-80. Available from: http://www.jiaps.com/text.asp?2017/22/3/179/207638

   Introduction Top

This is a case of a sharp foreign body causing duodenal perforation and liver injury 2 months after ingestion. The patient presented with mild symptoms and no peritonitis, and we performed an abdominal X-ray to put the patients mind at rest; however, it unexpectedly confirmed that the pin was situated in the patient's right upper quadrant and was indeed the source of her discomfort. There are other reported cases of perforations from sharp foreign bodies, but this case should highlight the possibility of patients presenting months later with minimal clinical signs.

   Case Report Top

An 11-year-old Muslim girl presented to the emergency department with a 4-day history of constant sharp pain in her right upper quadrant that was worse when doing exercise and walking. She felt mildly nauseous, but there were no other gastrointestinal symptoms. Two months previously, she had accidently swallowed a pin after putting it in her mouth while adjusting her hijab. She reported that she had never passed the pin and had been experiencing some pain on and off in the last few months.

On examination, she looked well; however, her heart rate was 107/min with a low-grade temperature of 37.7°C. On examination, there was mild tenderness of the right upper quadrant, but her abdomen was soft with no signs of peritonitis. An abdominal X-ray showed the pin in the right upper quadrant [Figure 1].
Figure 1: Abdominal X-ray showing pin in the right upper quadrant

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She was taken to theatre and the pin had eroded through her duodenum into her liver with significant inflammation and pus.

   Discussion Top

Ingestion of foreign bodies is common in the pediatric population with the majority of small nonsharp, nonbattery objects passing through the gastrointestinal tract without problem.

Sharp objects such as hairpins, open safety pins, and needles have been reported to cause perforation.[1],[2] The patients mostly present soon after ingestion and the site of obstruction is the esophagus in 75% of cases.[3]

A study in India reported 75 girls who accidentally ingested headscarf pins. All patients were admitted, and 48% had the pin successfully removed by upper gastrointestinal tract endoscopy. The rest were managed conservatively, but 2.6% developed peritonitis requiring laparotomy and one patient died.[4]

Aspiration of these pins has also been well reported. Ilan et al. described the mechanism of aspiration in a series of 26 women who were found to hold the pin in their mouths but aspirated it while talking or laughing. Two of those women required thoracotomy for removal.[5]

The American Society for Gastrointestinal Endoscopy's guideline on the management of ingested foreign bodies advises endoscopic removal of sharp, pointed objects that have passed into the stomach or proximal duodenum. If this cannot be done safely, patients should have daily radiographs to document passage, with surgical intervention if this does not occur. Patients should be instructed to immediately report symptoms such as abdominal pain, vomiting, fever, and hematemesis.[6] Conversely, a clinical report by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition in 2015 recommended that radio-opaque sharp foreign bodies in the small bowel can be managed conservatively with serial X-rays unless it has not passed within 3 days or if symptoms develop.[7]

This case highlights the danger of holding hijab/turban pins in the mouth and the possibility of a foreign body causing perforation 2 months after ingestion. There may not be the classical clinical signs of perforation in these patients. In well patients with pins seen on X-ray in the stomach or duodenum at presentation, we recommend that a repeat X-ray is performed in 72 h unless the item has passed spontaneously. If it has not passed the duodenum at this time, it will need to be removed surgically, even if the patient is asymptomatic. Patients should be carefully warned of signs to look out for and return earlier if they develop.

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There are no conflicts of interest.

   References Top

Stricker T, Kellenberger CJ, Neuhaus TJ, Schwoebel M, Braegger CP. Ingested pins causing perforation. Arch Dis Child 2001;84:165-6.  Back to cited text no. 1
Mehran A, Podkameni D, Rosenthal R, Szomstein S. Gastric perforation secondary to ingestion of a sharp foreign body. JSLS 2005;9:91-3.  Back to cited text no. 2
Wright CC, Closson FT. Updates in pediatric gastrointestinal foreign bodies. Pediatr Clin North Am 2013;60:1221-39.  Back to cited text no. 3
Mir SA, Dar HM, Dogra V, Gilkar IS, Ahmad MM. Accidental ingestion of hairpins in adolescent Muslim girls while doing or undoing the headscarf. Int Surg J 2015;2:377-80.  Back to cited text no. 4
Ilan O, Eliashar R, Hirshoren N, Hamdan K, Gross M. Turban pin aspiration: New fashion, new syndrome. Laryngoscope 2012;122:916-9.  Back to cited text no. 5
American Society for Gastrointestinal Endoscopy (ASGE). Guideline on the management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011;73:1086-91.  Back to cited text no. 6
Kramer RE, Lerner DG, Lin T, Manfredi M, Shah M, Stephen TC, et al. Management of ingested foreign bodies in children: A clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr 2015;60:562-74.  Back to cited text no. 7


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