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Introduction: Foreign body ingestion in children is considered a common concern in every Emergency Department worldwide. In the United States, it is estimated that foreign body ingestions cause approximately 1,500 deaths yearly (1). Safety pins ingestions are estimated to be 1% of the foreign body ingestions in children (2). In literature, ingested safety pins have been reported to be lodged mostly in the upper gastrointestinal tract, but a few cases have been reported to be lodged in the appendix (2,3,4). Objective: Recommendations for safety pin ingestions when past the second portion of the duodenum. Case: We report the case of a 5-year-old previously healthy female who presented with an accidental ingestion of an open safety pin. Following ingestion, the patient visited a local Emergency Room where an abdominal X-ray revealed an open safety pin located in the stomach. The patient was asymptomatic and had vital signs within normal limits for age with a normal exam. The patient was then transferred to a Children’s Hospital for further management and care; after traveling three hours, a follow-up X-ray on arrival to our Children’s Hospital revealed the safety pin to be located in the left upper quadrant (fig.1). As the patient continue to be asymptomatic, it was decided to continue monitoring progression with serial abdominal X-rays and initiate a bowel cleanout with GoLytely. Serial abdominal X-rays initially showed progression of the safety pin through the digestive tract and the patient remained asymptomatic. On the third day of admission, a repeat abdominal X-ray did not show progression of the safety pin and it appeared to be lodged in the right lower quadrant. At that time it was decided that the patient should undergo a colonoscopy with foreign body removal. During the procedure, the open safety pin was found in the appendiceal orifice with the head inside the Bauhin’s valve (fig.2). Careful extraction with rat-tooth forceps was performed; a pediatric surgeon was at the bedside for emergency abdominal decompression in case of appendiceal perforation. The open safety pin was successfully removed endoscopically without further damage to the patient’s colon. Conclusion: As per the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), sharp foreign bodies should be removed immediately when located in the stomach or intestines if the patient is symptomatic (5). In asymptomatic patients with sharp foreign bodies in the stomach or small intestine, it is recommended that these be removed endoscopically within 24 hours if possible (5). Surgical intervention should be considered if there is no spontaneous clearance of the sharp object after 3 days (5). It has been reported in the literature by Gün et al., that ingested safety pins passing through the duodenum can be excreted spontaneously (6). In our case, the ingested open safety pin failed to advance on serial abdominal X-rays and appeared to be lodged in the right lower quadrant, and the safety pin was then found to be in the appendiceal orifice during colonoscopy. A metallic foreign body lodging in the appendix is a rare finding. Benizri et al. reported a case of a 29-year-old with abdominal pain who was found to have a metallic foreign body in the RLQ; serial x-ray one month later showed unchanged position (4). In this case they were unable to retrieve the foreign body by endoscopy due to inability to enter Bauhin’s valve to extract the object (4). Compared to our case, early serial x-rays and measuring progression to determine timing of extraction could prevent possible perforation or inflammation of the appendix and may lead to improved ability to remove the object endoscopically.
Gastroenterology | Pediatrics
Biller, Alex; Alatorre-Jimenez, Moises; Stewart, Jeremy; and Abdelhadi, Ruba A., "Endoscopic Removal of Safety Pin from Appendiceal Orifice" (2022). Posters. 299.