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Foreign body ingestion is a challenging clinical presentation familiar to most gastroenterologists. In this edition of Frontline, Yadollahi et al report on a large series of such patients in their tertiary referral centre in Southampton.1 The authors describe an increasing incidence of foreign body ingestions over a 5-year period, discuss the outcomes of endoscopic management and relate the anticipated burden of this increasing presentation on staff and resources in their hospital.
This is a welcome and detailed addition to the small body of literature on the subject. The episodes of foreign body ingestion described by the authors of this article (who are all clinical gastroenterologists) are acts of self-harm. Terms such as ‘parasuicide’ and ‘deliberate self-harm’ have been superseded by this now preferred term. Foreign body ingestion is a small subset of such behaviours—the most common being overdose and cutting. Young people who self-harm have a substantially increased risk of adverse non-fatal and fatal outcomes, including suicide, compared with those who do not, yet most episodes of self-harm never result in a medical presentation. In a survey of adults from England aged 16–74 years, the prevalence of self-reported lifetime non-suicidal self-harm increased from 2.4% in 2000 to 6.4% in 2014, most notably in females aged 16–24 years, in whom prevalence increased to 19.7% in 2014.2 The reasons behind this remain unclear.
Self-harm is a complex behaviour and represents the final common pathway of a number of upstream risk factors. It can be a presentation of almost any psychiatric disorder. It is seen in depression, anxiety, obsessive compulsive disorders, eating disorders and psychotic illnesses as well as in patients with emotionally unstable personality disorders. Importantly, it is pathognomic of none of these, and self-harm presentations are very commonly seen in patients who, although distressed, have no diagnosable mental illness.
The authors, and many others, use the term ‘intentional’ foreign body ingestion to differentiate such presentations from accidental ingestion, yet it is not clear how a conclusion as to the patient’s intent at the point of ingestion could be drawn. Taking retrospective accounts from vulnerable patients at a time of distress will unavoidably produce a range of responses that should be interpreted with caution and sympathy by a treating endoscopist. While foreign body ingestion (whether intentional or not) does appear to be increasing, it is still an unusual presentation and accounts for only a very small proportion of all endoscopies, including out of hours. The 239 cases reported here over 5 years represent less than a single case per week for this large referral centre, compared with an estimated incidence of acute upper gastrointestinal haemorrhage in the UK of 134 per 100 000 population.3
The article concentrates on the endoscopic management of these patients. In doing so, little is understood about the patients themselves. It is noted that 42% were from forensic psychiatric institutions and 25% were from other psychiatric units, with only 36% from the community. Psychiatric and prison services commonly see the same patients who share many of the same vulnerabilities—high rates of adverse childhood experiences, low educational attainment, precarious employment, if any, and poverty. Other studies of foreign body ingestion have identified learning disability as a risk. This would be no surprise—7% of the UK prison population has a learning disability compared with just over 2% of the general population. One interesting finding from this paper was that most patients were female, whereas other studies of foreign body ingestion (as opposed to other forms of self-harm) have reported more even gender splits, or a male predominance. It is not clear what may be behind such variation, though ascertainment bias noted by the authors is likely.
Vulnerable, traumatised, isolated or impoverished patients are not always easy to care for, but it is precisely these vulnerabilities that make the provision of care so important. Pejorative attitudes to patients make the provision of care by professionals and the receipt of care by patients more difficult. Describing patients as ‘manipulative’ should be avoided. Acknowledging that the caring professionals may experience feelings of ‘stress’, ‘anger’ or ‘powerlessness’ is important but should lead to support for the professional. Many clinicians find the experience of patients either not getting better or returning with the same problem, uncomfortable, but this should not result in blaming the patient and separating patients into ‘accidental’ (ie, deserving) and intentional ingestion (ie, undeserving) will not improve outcomes.
One suggestion in this article is that a delayed endoscopy might ‘remove the instant gratification’ and ‘deter repeat attenders’, yet there is no evidence that an endoscopy whether at night or in the day is ‘gratifying’, nor that delaying might remove such gratification or that this might deter attenders. Such a view feels uncomfortably like the withholding of appropriate analgesia when suturing patients who have self-harmed and would be nothing less than punishment if pursued as policy.4
Such opinions should not deter from a discussion about appropriate timing for endoscopy in these patients, but this should be predicated simply on an evaluation of the evidence for clinical harm from delay versus the demands of urgent or emergency endoscopy on already busy units. In this series, 74% of endoscopic retrievals were performed from 08:00 to 20:00 (daylight hours), 69% had a general anaesthetic and a protective overtube used in 48%. Only four patients required surgery as a consequence of inability to remove items endoscopically. None of the 239 episodes in 51 patients resulted in major complications, though two cases involved deep ulceration, implying a risk of perforation if left much longer.
In comparison to the European Society of Gastrointestinal Endoscopy recommendation for emergency (preferably within 2 hours) endoscopy for foreign bodies inducing complete oesophageal obstruction and for sharp-pointed objects or batteries in the oesophagus, the authors report a median time to extraction of 6 hours (range 3–18 hours) for such patients with no major consequences.5 These data suggest that while such objects should be removed quickly, the timing of the procedure requires a careful individual balance of risks and benefits and that, while caution should be the first priority, performing the procedure first thing the next day may be appropriate in carefully selected cases. However, case numbers in this study are small and further data are urgently needed to support such judgements.
Liaison psychiatrists work within the general hospital and have expertise in the management of patients with physical and mental comorbidities. They have two ‘customers’—the patients they are asked to assess and the team referring them. Supporting the team looking after a patient with psychological or psychiatric difficulties can sometimes be more effective than simply providing direct care to the patient. Improvements to the longer-term management of patients who self-harm is a bigger task and, while necessary and important, is not solely within the gift of either gastroenterology or liaison psychiatry. While recognising and managing the impact of increased incidence of foreign body ingestion on endoscopy services are essential, improving the care of the patient in front of us most certainly can be achieved by a greater understanding of these patients and enhancing collaboration between gastroenterology and liaison psychiatry, which should be the main lesson that we can take from this article.
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Contributors Both authors contributed equally to this article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.