Aktay, Atiye N.; Werlin, Steven L.
Department of Pediatrics, Division of Pediatric Gastroenterology, The Medical College of Wisconsin and The Children's Hospital of Wisconsin, Milwaukee, Wisconsin, U.S.A.
Received April 10, 2001;
revised July 12, 2001 and September 17, 2001; accepted September 24, 2001.
Address correspondence and reprint requests to Dr. Steven Werlin, Department of Pediatrics, The Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 U.S.A. (e-mail email@example.com).
In the United States, approximately 1,500 people die annually of complications of ingested foreign bodies (1). Eighty percent of foreign body ingestions occur in children (2). Of foreign bodies that pass the esophagus into the stomach, 80% to 90% pass spontaneously through the gastrointestinal tract, whereas 10% to 20% are removed endoscopically. The rate of perforation from foreign body ingestion is estimated at less than 1%(1–3). Less than 1% require surgical intervention. Sharp objects account for 15% to 35% of perforations (4). Most of the small sharp objects such as nails, screws, and straight pins pass uneventfully through the gastrointestinal tract. The treatment of small sharp object ingestion in children is controversial because some authorities advocate early endoscopic removal when the sharp object is located in the esophagus or stomach and others recommend endoscopic removal only if the object fails to dislodge or results in intestinal obstruction (5,6). We report successful endoscopic retrieval of a straight pin, which became impaled in the antrum in a 7-year-old.
A 7-year-old boy was admitted to the surgical service at the Children's Hospital of Wisconsin 12 hours after accidental ingestion of a straight pin. He had a single episode of vomiting and mild abdominal pain 2 hours after the ingestion. Physical examination was normal. An abdominal radiograph revealed a straight pin in the stomach. The next day, follow-up radiograph demonstrated no change in the location of the pin. The patient continued to have mild abdominal pain and nausea. Because the location of the pin had not changed, a gastroenterology consultation was requested and the patient underwent an upper endoscopy. The straight pin was found impaled about 1 cm into the wall of the antrum (Fig. 1). There was erosion of the gastric mucosa on the opposite wall caused by irritation from the blunt tip. The blunt tip was grasped with a polypectomy snare, pulled close to the distal end of the endoscope, and retrieved. The pin was 5 cm long. The patient was discharged the next day after resolution of symptoms.
Although most sharp-pointed objects that enter the stomach will pass through the remaining gastrointestinal tract without incident, the risk of complications caused by sharp object ingestion is as high as 35%(4). There are several reports in the literature of complications from ingested sharp-pointed objects. Maleki and Evans (7) described 12 cases of intestinal perforation by sharp objects (chicken bones, toothpick, fish bones, and hat pin). Penetration and perforation of the stomach from sewing needles, cardiac tamponade from ingestion of an open safety pin, and duodenocaval fistula from toothpick ingestion have been reported (8–11).
There is little published information on straight pin ingestion. Ronald and Jaffe (12) reported two cases of straight pin ingestion; one patient developed intestinal perforation and abdominal abscess after several days and the second patient passed a straight pin without complications. Our case is the first report of straight pin ingestion in a child that resulted in penetration of the stomach.
Swarbick et al. (6) and Gillespie (13) suggested routine endoscopy to remove sharp-pointed objects within the reach of the endoscope. The American Society of Gastrointestinal Endoscopy consensus guidelines recommend endoscopic removal of all sharp objects that have not passed the stomach or proximal duodenum in adult patients (14). However, several authors consider straight pin ingestions as safe and treat them conservatively. Webb (15) recommended the retrieval of sharp objects, other than straight pins, that remain in the stomach. Byme (16) also suggested a conservative approach: high roughage diet for small sharp object ingestions such as nails, screws, and straight pins. Ronald et al. (12) reported the uncomplicated passage of a straight pin through the gastrointestinal tract and recommended serial radiographs to document the progression of sharp-pointed objects.
This case demonstrates important facts in the treatment of sharp-pointed objects and particularly straight pin ingestions in children. Like other sharp-pointed objects, straight pins not only may penetrate the stomach but also may lead to perforation. Multiple cases of perforation of the stomach and the duodenum from other sharp-pointed objects such as sewing needles and toothpicks have been described (8,9). Therefore, we suggest that straight pin ingestions should be treated according to American Society of Gastrointestinal Endoscopy consensus guidelines. The symptoms or the pin size did not play a role in our decision to perform endoscopy. Silent perforations from sewing needles have been reported (9). Although removing foreign objects longer than 5 cm in adolescence or older children and longer than 3 cm in infants and young children has been recommended, objects with pointed ends such as toothpicks and sewing needles have been retrieved endoscopically regardless of the size of the object (9,11,14,15). In our case, the surgeons opted to observe the patient with serial abdominal radiographs. Endoscopy was performed immediately after the gastroenterology service was consulted, which was 36 hours after the ingestion of the straight pin. We recommend obtaining an initial abdominal radiograph to document the location of the ingested sharp object; if it is located in the stomach or proximal duodenum, immediate endoscopic intervention is required because penetration or perforation can occur.
American Society of Gastrointestinal Endoscopy consensus guidelines recommend daily abdominal radiographs for sharp-pointed objects that have passed beyond the reach of the endoscope and surgical intervention for objects that fail to progress in 3 consecutive days. Several authors also suggest daily abdominal radiograms to follow the passage of sharp-pointed objects such as hat pins, sewing needles, or similar type of objects that could lead to intestinal perforation (12,14,15). Because intestinal perforation has also been reported after straight pin ingestion, we believe that a straight pin that has passed beyond the reach of the endoscope should be followed daily with serial abdominal radiography to document its passage. If the straight pin appears lodged in the same location for 3 consecutive days, then surgical intervention may be considered (12,14,15). Some authors suggest water-soluble contrast radiography to document gastrointestinal perforation (9,12).
In conclusion, awareness among gastroenterologists of penetration of the stomach associated with straight pin ingestion can lead to early diagnosis of this complication and perhaps prevent perforation and other complications by timely endoscopic retrieval.
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