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Computed Tomographic Demonstration of Ingested Press-Through Packages Causing Small Intestinal Perforation

Takahisa Fujikawa, Misako Yuasa, Hideto Hayashi, Akira Tanaka

Takahisa Fujikawa, Misako Yuasa, Hideto Hayashi, Akira Tanaka, Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka 802-8555, Japan

Correspondence to: Takahisa Fujikawa, MD, PhD, FACS, Department of Surgery, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka 802-8555, Japan.
Email: fujikawa-t@kokurakinen.or.jp
Telephone: +81-93-511-2000
Fax: +81-93-511-3240
Received: May 1, 2016
Revised: July 3, 2016
Accepted: July 5, 2016
Published online: August 21, 2016

ABSTRACT

Press-through packages (PTPs) are regularly used to enclose drugs, and are increasingly seen in cases of ingested foreign bodies in the alimentary tract. Most cases of ingested PTP-induced bowel perforation are difficult to diagnose. We herein present a case of preoperative computed tomography (CT) demonstration showing ingested PTP-induced small intestinal perforation. An index of high suspicion and early exact diagnosis by high-resolution CT are requisite to avoid deterioration of the patients’ condition and to improve outcome.

Key words: Press-through package; Small intestinal perforation; Computed tomography

© 2016 The Authors. Published by ACT Publishing Group Ltd.

Fujikawa T, Yuasa M, Hayashi H, Tanaka A. Computed Tomographic Demonstration of Ingested Press-Through Packages Causing Small Intestinal Perforation. Journal of Gastroenterology and Hepatology Research 2016; 5(4): 2056-2057 Available from: URL: http: //www.ghrnet.org/index.php/joghr/article/view/1702

LETTER TO THE EDITOR

An 81-year-old Japanese male presented with abdominal pain. Right lower quadrant tenderness was detected on palpation and serum biochemistry revealed severe leukocytosis. High-resolution abdominal plain CT showed free air around the small intestine (Figure 1A). The images also demonstrated a round low-density shadow with an internal high-density part inside the small intestine (Figure 1A) and another similar low-density shadow accompanied by linear high-density parts (Figure 1B), both of which were compatible with certain foreign bodies. On repeated questioning, she had accidentally ingested press-through packages (PTPs), and thus a diagnosis of small intestinal perforation resulting from ingested PTPs was made. The patient underwent an emergency laparotomy, revealing a laceration of the middle ileum due to a PHP (Figure 1C). Exploration of the more distal part of the ileum also revealed another PHP by palpation. Extraction of two PHPs followed by partial resection of the lacerated ileum was performed (Figure 1D). His postoperative course was uneventful and was discharged in stable condition.

PTPs are regularly used to enclose drugs, which consist of a dome of polyvinyl chloride and a rupturable aluminum lid. They are increasingly seen in cases of ingested foreign bodies in the alimentary tract, and their sharp edges may occasionally cause perforation of the intestine[1-3]. Most cases of ingested PTP-induced small bowel obstruction or perforation are difficult to diagnose[1,3,4], but some reports showed that PTPs were sometimes detected on CT[2,5], and the possibility of exact diagnosis might be increasing by high-resolution CT, like the current case. The specific characteristics of their CT images, such as a round low-density shadow with an internal high-density part (Figure 1A) or low-density shadow accompanied by linear high-density parts (Figure 1B), might be helpful for diagnosis. An index of high suspicion and early exact diagnosis by high-resolution CT are mandatory to avoid deterioration of the patients’ condition and to improve outcome.

CONFLICT OF INTERESTS

The authors declare that they do not have conflict of interests.

REFERENCES

1Hashizume T, Tokumaru AM, Harada K. Small intestine perforation due to accidental press-through package ingestion in an elderly patient with Lewy body dementia and recurrent cardiopulmonary arrest. BMJ Case Rep 2015; Dec 17; 2015. pii: bcr2015212723. doi: 10.1136/bcr-2015-212723.

2Domen H, Ohara M, Noguchi M, Nakanishi Y, Komuro K, Iwashiro N, Ishizaka M. Inadvertent Ingestion of a Press-Through Package Causing Perforation of the Small Intestine within an Incisional Hernia and Panperitonitis. Case Rep Gastroenterol 2011; 5(2): 391-395.

3Norstein J, Krajci P, Bergan A, Geiran O. Intestinal perforation after ingestion of a blister-wrapped tablet. Lancet 1995; 346(8985): 1308.

4Gupta V, Manikyam SR, Gupta R, Gupta NM. Pelvic abscess after ingestion of blister-wrapped tablet. Am J Gastroenterol 2002; 97(8): 2142-2143.

5Traub SJ, Hoffman RS, Nelson LS. Body packing--the internal concealment of illicit drugs. N Engl J Med 2003; 349(26): 2519-2526.

Peer reviewer: Osamu Handa, Deptrtment of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachi-Hirokoji, Kamigyo, Kyoto. 602-8566, Japan.

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