|Year : 2014 | Volume
| Issue : 2 | Page : 111-113
Anorectal impaction of fish hook following ingestion in a mentally unstable adult
Paingha J Alagoa1, Chukuemeka Agi2, Jerry Oseh3
1 Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria
2 Department of Radiology, University of Port Harcourt, Port Harcourt, Nigeria
3 Department of Surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
|Date of Web Publication||16-Oct-2014|
Paingha J Alagoa
Department of Surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State
Source of Support: None, Conflict of Interest: None
Ingestion of foreign body (FB) is known to occur in both children and adults. In adults, it is mainly accidental, although it may be intentional in the mentally unstable. Various objects have been swallowed by such individuals. We recently managed a 28-year-old schizophrenic who presented to us with an impacted fish hook in the rectum which he had swallowed. The fish hook which was protruding was removed under local anesthesia. This case highlights the fact that all sorts of bizarre objects may be ingested by the mentally unstable. Careful examination and investigation is usually followed by successful outcome of treatment
Keywords: FB ingestion, fish hook impaction, schizophrenic adult
|How to cite this article:|
Alagoa PJ, Agi C, Oseh J. Anorectal impaction of fish hook following ingestion in a mentally unstable adult
. Arch Int Surg 2014;4:111-3
| Introduction|| |
Intentional ingestion of foreign bodies in adults is not usual. It is mostly encountered in children who may swallow toys and other play items.  Most cases of foreign body ingestion in adults are accidental except in prisoners and the mentally insane in which bizarre objects are involved. 
Most ingested foreign bodies which are able to pass through the esophagus would eventually go through the gastrointestinal tract and are passed out per rectum without serious consequences.  However, some have resulted in serious complications including impaction and perforation in certain portions of the gastrointestinal tract.
Herein, we report a bizarre case of ingestion of a fish hook by a mentally unstable adult who we managed. The patient presented with an impaction of the fish hook in the rectum.
| Case Report|| |
Mr. AA, a 28-year-old unemployed male schizophrenic was referred to the surgical out- patient clinic from the Psychiatric unit with a one-day history of anal pain and protrusion of a fish hook through the anus. He was an old patient of theirs who was diagnosed as a schizophrenic 3 years ago and was apparently stable on medications. Before this visit to hospital, he had been lost for follow-upvisits for about 4 months. He was said to have been in the process of defecation when he developed a sudden sharp pain in his anus and felt a metallic object protruding from the anal verge. He admitted swallowing a fish hook intentionally some days earlier. He had first anchored the sharp point of the hook to a small piece of bamboo before swallowing with warm water. He could not explain the reasons for his actions. He also denied suicide as a possible reason. He did not notice any pain or discomfort after ingesting the fish hook until that morning when on defecation, he noticed slight blood along with the stool.
On examination, we found a young man in a poor hygienic state, he was calm and co-operative. Rectal examination revealed peri-anal induration with slight mucosal protrusion with an impacted metallic shank and eye of a fish hook protruding from the anus at 11 o'clock [Figure 1]. Local anesthesia was administered and the fish hook was manually manipulated and removed [Figure 2]. He was observed on the ward for 2 days. Plain abdominal X-ray did not reveal any other foreign body. Patient was sent home on saline sitz baths, oral antibiotics and analgesics. He has done well with complete resolution of anal pain and swelling.
| Discussion|| |
Ingestion of foreign body by humans is fairly common affecting several thousand with an estimated annual mortality of over 1,500.  Both adults and children are involved in this act. Generally, different groups of people have been known to swallow foreign bodies intentionally. These include children, patients with mental illness and intellectual impairment, 'drug- mules' who traffic hard drugs and those with trichobezoar. ,,,
Children account for over three quarters of patients with foreign body in the gastrointestinal tract.  Any foreign body which can pass through the pharynx can be swallowed hence children have swallowed coins, small toys, parts of pencils, batteries, needles, hair pins among others. A study showed coins to be the most common foreign body ingested by children.  Food related objects are also ingested like fish and chicken bone. Most objects will pass through the gastrointestinal tract and get expelled in the feces. It is in fact estimated that 80-90% of foreign bodies reaching the stomach would eventually be passed out. 
In adults, accidental ingestion of dentures or parts of it is common.  Most cases of foreign body ingestion in adults are accidental. Our patient was a known schizophrenic on treatment. It was reported in a study that about 22.9% of adults who have intentionally swallowed foreign bodies had a history of psychosis.  Objects swallowed include razor blades, screws, bolts, coins and even bullets.  Such bizarre objects are similar to the fish hook swallowed by our patient. There is apparently no pattern as to the type of objects ingested. It is agreed that the state of delusion and hallucinations are major contributory factors. Our patient did not reveal to anyone that he had ingested a fish hook until the pain from the impaction became unbearable.
Most foreign bodies in the cricopharynx and upper oesophagus can be removed endoscopically. However, foreign bodies which eventually reach the stomach are monitored with serial abdominal X-rays, if radio-opaque or for the development of symptoms since it is known that 80% of them would be passed out eventually.  A small number may develop complications and may therefore require surgical intervention.It should also be noted that certain persons introduce foreign bodies through the rectum also as part of sexual gratification. This was found to be more common in men, particularly between the ages of 30 and 40 years. , Such practice has not been reported in literature in Nigeria and our patient also persistently denied anal introduction of the fish hook.
| Conclusion|| |
This case further reveals the challenges of caring for the mentally ill. The bizarre and un-predictableness of the types of foreign bodies that can be ingested is also highlighted. There must therefore be a high index of suspicion when managing a schizophrenic who presents with possible signs of complications of foreign body ingestion.
| References|| |
Hurtado CW, Furuta GT, Kramer RE. Etiology of esophageal food impactions in children. J Pediatr Gastroenterol Nutr 2011;52:43-6.
Web WA. Management of foreign bodies of the upper gastrointestinal tract: Update. Gastrointest Endosc 1995;41:39-51.
Lin CH, Chen AC, Tsai JD, Wei SH, Hsueh KC, Lin WC. Endoscopic removal of foreign bodies in children. Kaohsiung J Med Sci 2007;23:447-52.
Alrazzak BA, Al-Subu A, Elitsur Y. Etiology and management of esophageal impaction in children: A review of 11 years. Avicenna J Med 2013;3:33-6.
Silverberg D, Menes T, Kim U. Surgery for 'body packers' - A 15-year experience. World J Surg 2006;30:541-6.
Andrus CH, Ponsky JL. Bezoars: Classification, pathophysiology, and treatment. Am J Gastroenterol 1988;83:476-8.
Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of literature. Eur J Pediatr 2001;160:468-72.
Wu WT, Chiu CT, Kuo CJ, Lin CJ, Chu YY, Tsou YK, et al
. Endoscopic management of suspected foreign body in adults. Dis Esophagus 2011;24:131-7.
Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingestion of foreign bodies of the gastrointestinal tract: A retrospective analysis of 542 cases. World J Surg 1996;20:1001-5.
Soong CV, Harvey C, Doherty M. Self- mutilating behaviour and deliberate ingestion of foreign bodies. Ulster Med J 1990;59:213-6.
Ooi BS, Ho YH, Eu KW, Nyam D, Leong A, Seow-Choen F. Management of anorectal foreign bodies: A cause of obscure anal pain. Aust N Z J Surg 1998;68:852-5.
[Figure 1], [Figure 2]