Bitter pill to swallow: case report of ileal perforation caused by accidental ingestion of a blister pill package

Abstract

Whilst the accidental ingestion of foreign bodies is common, the incidence of gastrointestinal perforation from foreign bodies is reported to be <1%. Most ingested foreign bodies pass through the gastrointestinal tract without incidence; however, objects with sharp edges such as fish bones, chicken bones and toothpicks can cause perforation. Blister packaged pills (BPPs) are being increasingly reported as a cause of gastrointestinal perforation. BPPs, also known as press-through packages, account for 85% of the packaging for all solid medications in Europe. They are made up of a dome-like cavity usually formed by thermoformed plastic and enclosed by a lid of aluminium foil. The individual portions of the BPP can be divided and the sharp edges of the aluminium lid can cause damage to the gastrointestinal tract if ingested. In this study, we report a case of ileal perforation caused by the inadvertent ingestion of a BPP. An 88-year-old woman from home alone, independent of all activities of daily living, presented with 3 days of worsening generalized abdominal pain, associated with constipation and having only passed hard stools 3 days prior. She was still passing flatus but had decreased appetite and oral intake, one recent vomit, reported dark in nature, but no fevers or sweats. Her past medical history was significant for hypertension and peripheral oedema. She took only two regular medications, lisinopril and frusemide. She had no history of cognitive difficulties, dementia or psychiatric illness and had no previous abdominal surgeries. On examination, she had dry mucus membranes, heart rate was 70 bpm, blood pressure 100/50 mmHg and afebrile temperature of 36.7 C. Her abdomen was distended with generalized peritonism. Rectal examination revealed small hard stools, but no blood or palpable masses. Preliminary investigations revealed a leucocytosis, white cell count of 22 × 10/L and an acute renal impairment with creatinine elevated to 309 μmol/L and urea 20.1 mmol/L, with an estimated glomerular filtration rate of 11. A non-contrast computed tomography (CT) performed revealed pneumoperitoneum and free fluid surrounding the liver as well as diverticular disease, but no clear site of perforation. The patient was taken for an urgent laparotomy that revealed four quadrant purulent peritonitis with an approximate 20-cm hyperaemic section of ileum and a small 2-mm perforation of the bowel adjacent to the mesentery. Within this section of ileum, a mobile foreign body was palpated. The section of ileum was removed and side-to-side anastomosis performed. The resected ileum was explored and a tablet still within its intact plastic and aluminium packaging was found as the likely cause of perforation (Fig. 1). No other sites of perforation were identified. After thorough washout, the patient’s abdomen was closed. After 24 h of post-operation in the intensive care unit, the patient was transferred to the ward. The patient made an uneventful recovery and was discharged home after 8 days. Re-review of the patient’s initial CT revealed that the BPP within the small bowel could be seen, although it was missed on initial review of the CT preoperatively that had been formally reported by a radiologist (Figs 2,3). The patient did not recall accidentally swallowing the tablet within its packaging. Accidental ingestion of BPPs occurs most frequently in the elderly due to a culmination of multiple risk factors including poor Fig. 1. The foreign body identified as the cause of the small bowel perforation was found to be a blister packaged pill tablet.