Key findings:

The abstract underscores that while foreign body ingestion is common in pediatric and psychiatric patients, it usually passes uneventfully. However, in rare cases, surgical intervention is required due to complications like perforation. This case report details a 22-year-old male with schizophrenia who underwent laparotomy to remove a knife from the proximal jejunum.

What is known and what is new?

The abstract confirms the common occurrence of foreign body ingestion, typically passing through the gastrointestinal tract without complications. However, it highlights a unique case of a 22-year-old male with schizophrenia requiring surgery due to a lodged knife in the proximal jejunum, emphasizing the need for vigilance in psychiatric patient care.

What is the implication, and what should change now?

This case underscores the importance of recognizing the heightened risk of foreign body ingestion in psychiatric patients, necessitating increased vigilance and preventive measures. Healthcare providers should prioritize comprehensive psychiatric evaluations and implement strategies for minimizing access to potentially harmful objects to prevent such incidents and subsequent surgical interventions.

Ingestion of foreign bodies is occasionally encountered in the emergency department. In prior studies, around 1% of foreign body ingestion complicates with significant clinical sequel like

Gastrointestinal tract obstruction or hollow viscus perforation [1]. In many cases, foreign body ingestion occurs repeatedly in a small population of patients and can consume a large percentage of healthcare related costs. This was demonstrated in a retrospective case study [2,3] in which 305 cases were associated with only 33 patients. Psychiatric diagnoses were identified in 79 percent of these patients and total cost for management of the cases totaled over $2 million.

Psychiatric patients may engage in foreign body ingestion as a result of their delusional beliefs or in response to command hallucinations. In one series, 22.9% of the patients had some history of psychosis [4]. One article reports the case of a patient with schizophrenia who died of the systemic effects of zinc intoxication after swallowing 700 coins [5]. Another notes a patient, again with a diagnosis of schizophrenia, who required aggressive treatment for lead poisoning after the ingestion of 206 bullets.

A 22-year-old young man was admitted to the psychiatric department of our hospital with a diagnosis of schizophrenia for the last 20 days. He has been complaining of pain abdomen for the last 2 days. There was no history of nausea, vomiting or any other gastrointestinal symptoms. His vitals were stable and abdominal examination was within normal limits. Blood investigations were within normal limits. Abdominal plain x-ray shows radio-opaque shadow at the level of L1-L2 (fig.1). Plain x-ray abdomen was done two times to rule out whether this radio opaque shadow is intra-abdominal or extra-abdominal after thoroughly examining the clothes of the patient. Exploratory laparotomy with enterotomy with retrieval of foreign body (knife) from proximal jejunum with primary closure of enterotomy was done (fig.2). On opening the abdomen a hard object felt at the proximal jejunum about 17cm from DJ. Blunt end was distal and sharp end proximal. Entrotomy was done and 17cm long (9.5cm plastic end and 7.5cm sharp blade) and 1cm wide knife was retrieved. Post-operative period was uneventful and the patient was discharged on 6^th post-operative day. (fig.3)

Fig1:- Plane Xray Abdomen Showing Knife as Foreign Body in Abdominal Cavity

Fig2:- Intraoperative Picture Showing Foreign Body Just Beyond the DJ

Fig 3:- 17 Cm Long Knife was Retrieved

Foreign body ingestion is a common event in children from 6 months to 3 years of age. Foreign body ingestion is frequently seen in prisoners, psychiatric patients and alcoholics. In about 80% of cases, the ingested material passes uneventfully through the gastrointestinal tract, endoscopy is performed in about 20% of cases and surgery in less than 1%. Small objects generally pass through the gastrointestinal tract without complication. Large sharp or caustic ingested foreign bodies cause severe complications like gastrointestinal perforation. Overall risk of perforation is 1%. Most common site of perforation is the esophagus. Othersites pylorus, duodenum, duodeno- jejunal flexure, ileo-caecal junction, Meckelʼs diverticulum or previous surgical sites.

Funding: No funding sources

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee of Indira Gandhi Medical College & Hospital.

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2. Ngan, John HK, et al. "A prospective study on fish bone ingestion: experience of 358 patients." Annals of surgery 211.4 (1990): 459-462. https://journals.lww.com/annalsofsurgery/citation/1990/04000/A_Prospective_Study_on_Fish_Bone_Ingestion_.12.aspx 
3. Pfau, Patrick R. "Removal and management of esophageal foreign bodies." Techniques in Gastrointestinal Endoscopy 16.1 (2014): 32-39. https://doi.org/10.1016/j.tgie.2013.10.004 
4. Ikenberry, Steven O., et al. "Management of ingested foreign bodies and food impactions." Gastrointestinal endoscopy 73.6 (2011): 1085-1091. https://doi.org/10.1016/j.gie.2010.11.010 
5. Hasan, N., et al. "Chronic copper intoxication due to ingestion of coins: a report of an unusual case." Human & experimental toxicology 14.6 (1995): 500-502. https://doi.org/10.1177/096032719501400606