Journal of Surgery (ISSN: 2575-9760)

case report

A Case of Ingesting Foreign Objects by A Prison Inmate

Ahsan Zil-E-Ali1*, Muhammad Aadil1, Saad Asif1, Asad Ali2

1Department of Surgery, Fatima Memorial Hospital, Lahore, Pakistan

2Combined Military Hospital, Lahore, Pakistan

*Corresponding author: Ahsan Zil-E-Ali, Department of Surgery, Fatima Memorial Hospital, Lahore, 725 Shadman Rd, Lahore 54000, Pakistan. Tel: +9242111555600; Email:

Received Date: 12 November, 2017; Accepted Date: 23 November, 2017; Published Date: 30 November, 2017

The impact of psychiatric diseases is very strong and difficult to manage at times. It is important that psychiatric conditions in patients with previous mental issues and psychiatric medications are complicated cases and at times the diagnosis are overlapping among multiple diseases. We report a bizarre case of a prison inmate with a previous diagnosis of generalized anxiety disorder and an accused case of rape and murder. The patient’s vague symptoms and strange actions led to a medical emergency that was managed by endoscopy. The case serves as an important academic bridge between multiple specialties and can also address some conditions of prisoners.

1.      Introduction

The ingestion of foreign objects among inmates has been a topic of discussion in psychiatric research for decades. Accidental and intentional swallowing for foreign objects is a common problem in prison inmates all across the world including Pakistan. Unfortunately, there is no published data in Pakistan which can give us the true prevalence of such incidences. The main reasons for accidental ingestions and swallowing among inmates are psychiatric disorder, intellectual disability, alcoholism and dentures in old patients[1]. The motives behind intentional ingestion of foreign objects are various, including psychological reasons other than suicide. It can be done for secondary gains, like for attention, release to hospital or shifting to another jail, gaining access to narcotics or there can be behavioral or psychological elements like non-suicidal self-injurious behavior and suicidal intent[1]. There have been reports that prisoners can also ingest foreign objects to protest against prison authorities[2]. A study conducted by Rene Palata in 2009 studied 262 cases of foreign body ingestion and found that 92% of the cases were intentional and 85%involved psychiatric cases[3].This gives us insight about the importance to study and report more cases of in-prison foreign body ingestion.

We will like to report a case of an inmate with a history of non-compliance to medications and multiple emergency visits because of foreign body ingestion. He presented to the emergency facility after ingesting an unknown object which he refused to reveal. The patient had to undergo emergency endoscopic procedure resulting in retrieval of two metallic objects.             

2.      Case Description

A 44-year-old man accompanied by a police warden who presented to the emergency service with complaints of abdominal discomfort and irritability for the past 3 hours. On examination, he was conscious and cooperative but agitated. He was afebrile, with a blood pressure of 144/88 mmHg, heart rate 98 beats/min and respiratory rate 22 breaths/min. On physical examination the patient has mild to moderate epigastric tenderness, dark skin pigmentation on his neck and several circular scar marks on his forearms. According to the police warden, the patient ingested an unknown object before the onset of symptoms but refused to reveal its nature. A detailed history was taken from the attending police warden who was in possession of previous medical records showed that the patient was an uneducated man accused of rape and murder, and has been under prison custody for almost 8 years. According to the warden, the patient had been acting strangely since his arrest. Initially he was diagnosed with Generalized Anxiety Disorder by the in-house psychiatrist and was prescribed buspirone. The patient refused to take the medication and has been noncompliant with any treatment provided, even for respiratory and gastrointestinal infections.

The patient also had a history of ingesting inedible and sometimes potentially lethal substances. For instance, he was found drinking from the urinal and eating feces from his cell toilet. He was also provided with prescription spectacles on the advice of an ophthalmologist for his headaches and later, he ingested the glass lenses. On another occasion, he ingested a used needle and had to be shifted to emergency for treatment. Since his imprisonment this is the fourth hospitalization and he had undergone two endoscopic procedures for retrieval of ingested foreign objects.

After getting the relevant history and physical examination in the emergency department, relevant laboratory test was ordered, and X-ray abdomen was done which showed presence of foreign object in his stomach. Leukocyte count and C-reactive protein were elevated. A CT-scan was ordered then immediately, and surgical consult was done who. The surgeons ordered an emergency endoscopic procedure and successfully recovered two pieces of metallic objects measuring up to 3.0 x 0.8 x 0.2 cm. The patient was kept in the inpatient unit for 1 week before discharge(Figure 1).

The patient has had several sessions with the in-prison doctor and a visiting psychiatrist, but no definitive diagnosis has been made. According to his psychiatric record, the patient is very friendly with the other inmates and no violent encounters were ever reported. He is fond of talking about his family; he told many fellow inmates and the psychiatrist that his wife divorced him 3 years before he was arrested, and that she was having illicit sexual relationships with multiple male partners.

3.      Discussion

This case is a good example to signify the focus on the psychiatric aspect of foreign body ingestion, particularly in prisoners. Studies published to date mainly comprise case reports revolving around medical and surgical decisions made while treating such patients; however, recommendations for optimal psychiatric care options have rarely been outlined. Due to the wide spectrum of specific individual causes, i.e. organic or psychiatric, that can result in foreign body ingestion, there is a lack of data from larger series of patients.In this particular case the behavior was possibly triggered at the time of the arrest. In the absence of prior history, we cannot definitively conclude whether similar symptoms were present previously, or whether the arrest triggered them. Furthermore, whether the patient started this behavior because of an influence of the other prison inmates or he had a past history. His past and current history suggests an absence of drug abuse. The patient refusal to comply with any treatment for other infections, which suggests the possibility of acting out or passive aggression.

It is important to note that the patient continued ingesting foreign objects which included edible and non-edibles (needles, pen etc) which could have resulted in serious complications and despite of that refused treatment.The type of foreign objects ingested are quite similar to a study published by Tae Hee Lee in Korean prison and reported most commonly used foreign objects includes metal wires, ball tipped pens, toothbrushes and needles [4]This is an unusual finding in the context of available research, and an element of passive-aggressive behavior appears to be present in this case. Additionally, the patient has no other symptoms such as depression, crying spells, violent outbursts or social isolation which might point toward a specific psychiatric disorder. It is not clear whether the marks on his necks and forearm are because of non-suicidal self-injurious behavior because of distress, or whether the patient inflicted those for secondary gains.One of the focal issues in this case involves efforts to prevent future episodes of such incidents due to their high risk of recurrence and the associated health and financial burden. After an extensive literature review we found no evidence-based preventive strategies; however, efforts to closely monitor patients and provide early psychiatric intervention are among the recommended best-practice strategies. Because of stigma of psychiatric evaluation in Pakistan and limited access to doctors and funding in prisons, unfortunately not all patients gets access to mental health workers.

4.      Conclusion

Besides through evaluation, psychotherapy and pharmacotherapy should be offered to such patients and can be beneficial. In case of an emergency because of a possible sharp foreign object ingestion, conservative measurements should not be attempted, and an emergent endoscopic removal should be attempted. A good collaboration between prison doctor, nurses, jail warden, radiologist and surgeon can provide best assessment, treatment and prevent future recurrence of such cases.

Figure 1: Endoscopic (upper left), X-ray (lower left) and macroscopic images of the foreign bodies ingested by the man described in this report.