Mladen Nisavic, MS III Gillian Lieberman, MD

September 2008

Foreign Body Ingestion in Patients with Borderline Personality Disorder Mladen Nisavic Harvard Medical School Year III Gillian Lieberman, MD

Mladen Nisavic, MS III Gillian Lieberman, MD

Presentation Outline: 1.

Patient #1: introduction to evaluation of acute abdomen in a psychiatric patient; 1. 2. 3.

Radiologic imaging and differential diagnosis of acute abdomen Borderline personality disorder (brief introduction) Radiologic and surgical management of foreign object ingestion

2.

Patient #2: further exploration of BPD and foreign object ingestion 3. Supplementary case #1: Trichobezoars 4. Summary 5. References

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1: Initial Presentation •

SD is a 32 y.o. obese Caucasian female with PMH of asthma, poorly controlled DM, peripheral neuropathy, hypertension and viral meningitis. During the interview, one notes that the patient is a poor historian – she often whitholds information, and at times refuses to speak to the interviewer.

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CC: “My stomach does not feel so well”

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Physical exam reveals a diffusely tender abdomen (5/10 pain), with poorly defined pain (no localization to a particular quadrant). – No ascites noted on physical exam. – Decreased bowel sounds. – Absent splenomegaly/hepatomegaly.

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No occult blood noted on rectal exam. Patient reports no hematemesis, melena or hematochesia.

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Patient’s presentation is relatively non-specific and can be due to a number of different etiologies.

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1: Differential Diagnosis • Broad differential diagnosis for the initial presentation: – Metabolic: • Diabetic ketoacidosis, diabetic neuropathy-associated ileus • Gallstones (atypical presentation)

– Structural: • Early SBO (adhesions, hernia, volvulus), perforation,

– Inflammatory: • Peptic ulcer disease • Gastroenteritis, pancreatitis, colitis

– Vascular: • Myocardial infarction (atypical presentation) • Small bowel ischemia

– Gynecologic: • Ectopic pregnancy, tubo-ovarian abscess, ovarian CA

– Malignancy: • Stomach CA, pancreatic CA, small/large bowel CA, lymphoma

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Mladen Nisavic, MS III Gillian Lieberman, MD

•

Radiologic Evaluation of Acute Abdomen

Radiologic imaging, as well as basic blood/urine tests, are the most essential component of further narrowing the differential diagnosis in our patient.

BIDMC ED algorithm for evaluation of acute abdomen: 1. Rapid pregnancy test (done routinely in pre-menopausal females regardless of the type/location of abdominal pain). 1. If positive - pelvic ultrasound to evaluate for GYN problems. 2. If negative: 1. Complaints of RUQ pain (or suspicion of cholelithiasis) – RUQ ultrasound 2. Otherwise: 1. Abdominal plain film (both supine + upright). 2. Abdominal CT scan 3. Further specific imaging (MRI, arteriogram, nuclear imaging, etc) 5

Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1: Abdominal Plain Film (Unlabeled for Pathology)

PACS, BIDMC Patient 1: AP upright plain film of the abdomen.

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1: Abdominal Plain Film (Pathology Labeled)

Legend: Cholecystecomy suture/ clips Pen Batteries IUD Patient 1: AP upright plain film of the abdomen. Pathologic findings labeled.

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Radiologic Evaluation of Foreign Body Ingestion

• In addition to detecting/quantifying the foreign objects in the patient’s abdomen, radiologists must look for the presence/absence of associated pathology. • Often, upright chest X-rays are needed to assess for perforation of esophagus/stomach/intestine and resultant pneumothorax or pneumoperitoneum. Chest films are also useful for initial evaluation of foreign object-caused bleeding into the mediastinum and to rule out dreaded pericardial effusion/cardiac tamponade. 8

Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1: AP and Lateral Chest Films – Assessing for Perforation

Patient 1: AP upright chest X ray anterior view.

Patient 1: Upright chest X-ray lateral view.

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1: Further History • When confronted with radiologic findings, patient initially refuses to talk to the examiner. • Following day admits to longstanding diagnosis of borderline personality disorder. • CC: "I tried to hurt myself. . . life is not so wonderful." • Frequent episodes of depression, often “feels rejected” • Multiple past episodes of self-injurious behavior, including: – Superficial cutting of wrists and across the abdomen. – Ingestion of foreign objects (30+) including pens, metal clips and batteries – Insertion of foreign objects (e.g. pens) in her vagina – Numerous suicide attempts – jumping from a window, jumping in front of a car, acetaminophen overdose, hanging. 10

Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1: Treatment • Radiologic imaging is an essential component of assessment and treatment for these patients. •

Chief treatment options consist of: - Non-invasive/Minimally Invasive (more common) - Serial KUBs over the remainder of stay for evaluation of progress of foreign objects through the small/large intestine and development of any secondary pathology (e.g. perforation, obstruction) - Esophagogastroduodenoscopy (EGD) for direct visualization of objects in the upper GI tract. Possible removal of smaller objects (via a snare) in the stomach/esophagus at this point. - Invasive (less common): - Exploratory laparotomy with foreign object removal in case of severe obstruction or perforation. 11

Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1(Different Episode): Serial KUB 1.

Patient 1: Supine plain film of the abdomen. Ingested objects are within the stomach lumen

PACS, BIDMC 12

Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1(Different Episode): Serial KUB 2.

Patient 1: Supine plain film of the abdomen. Ingested objects are within the colon lumen

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1(Different Episode): Serial KUB 3.

Patient 1: Supine plain film of the abdomen. Note foreign objects in sigmoid colon.

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #1(Different Episode): Serial KUB 4.

Patient 1: Supine plain film of the abdomen. Patient passed foreign objects without major complications.

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Borderline Personality Disorder • •

Personality disorder – rigid and ongoing patterns of thought and action Cluster B (dramatic-erratic) disorders: WILD – Borderline, Antisocial, Histrionic, Narcissistic – Disturbances in impulse control and emotional regulation

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Borderline Personality Disorder: – DSM-IV criteria: • • • • •

– – – –

Frantic efforts to avoid real or imagined abandonment Pattern of unstable/intense interpersonal relationships Identity disturbance: marked and persistently unstable image of self Affect instability: rapid alterations in affect, difficulty controlling anger, etc. Impulsivity (e.g. promiscuous sex, eating disorders, substance abuse) and recurrent suicidal ideations/threats and/or self-mutilating behavior (cutting, burning, etc)

Common pattern is history of childhood abuse/neglect Tend to regress during hospital stay Employ splitting – causes arguments within the healthcare team. Treatment: no medical treatment (? SSRIs), mixed success with DBT 16

Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: Initial Presentation • • •

DD is a 41 y.o. homeless male, with history of HCV, borderline personality disorder (BPD), substance abuse, multiple suicide attempts and PTSD. Significant history of childhood sexual abuse by his parents. Patient presents with cycles (3-6 months) of self-injurious behavior, including cutting, burning and ingesting sharp objects (glass shards or razor blades) with primary gain of obtaining/maintaining medical and personal attention.

Examples of patient’s past presentations to the ED: • CC #1: "My whole life has been up and down... I can't get my life back… I'll harm myself until I kill myself“ • CC #2: "I'm going to kill myself because no one's helping me." • CC #3: "I swallowed razor blades."

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: Initial Presentation (cont’d) • Most recent admission: – CC: “…I swallowed glass” – Patient was released from a different hospital, and on the same day ingested 5 pieces of glass. Subsequently, he cut his neck with a beer can, then hung up rope at the park – with intent to “hang myself”. Was found by police and admitted at BIDMC. – At BIDMC ED patient reaffirmed pervasive suicidal/self-harming behavior and noted diffuse abdominal discomfort

• Patient management: • Initial radiologic evaluation for extent of GI trauma/foreign bodies; • Subsequent serial KUBs for evaluation of foreign body passage; – Monitor for complications including small bowel obstruction, pneumothorax, pneumomediastinum, pericardial bleeding, etc.

• Eventual (?) discharge to a long-term psychiatric facility

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: KUB on most recent admission

Legend: Glass shards Surgical clip

Patient 2: Supine plain film of the abdomen. Ingested objects are within the stomach lumen

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: AP and Lateral Upright Chest Plain Films (Most Recent Admission)

Patient 2: Upright Chest Plain Film AP view; Note the absence of significant pathologic findings other than the surfical clip in RUQ

Patient 2: Upright Chest Plain Film Lateral view; note absence of pathologic findings other than the surgical clip in RUQ.

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: KUB (Past Admission 1)

Legend: Razor blade Fragments of Sunglasses Metal wire Patient 2: Supine plain film of the abdomen. Some of ingested objects can be identified on the film.

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: KUB (Past Admission 2)

Patient 2: Supine plain film of the abdomen. Pathologic findings are not labeled

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: KUB (Past Admission 2)

Legend: Coin Fragments of a Lighter Fragments of a Coca Cola can Gastrografin contrast in the colon Patient 2: Supine plain film of the abdomen. Some of ingested objects can be identified on the film. Gastrographin contrast is visible in the lumen of the large intestine

PACS, BIDMC

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Mladen Nisavic, MS III Gillian Lieberman, MD

Patient #2: AP Upright Chest X-ray Illustrating the Complications During Most Recent Hospital Stay

During most recent hospital stay, patient ingested a tube of toothpaste (tube and all), as well as a metal paper clip, despite a sitter. Some of the objects are evident on this chest plain film

Patient 2: AP upright plain chest film

24 PACS, BIDMC

Mladen Nisavic, MS III Gillian Lieberman, MD

Companion Case #1: Trichobezoars •

Chronic hair ingestion (trichophagia) leading to formation of a hair ball (trichobezoar) within the lumen of the stomach.

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Associated with trichotillomania, mental retardation, OCD behavior and cluster B personality disorders (borderline).

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Rarely may progress to Rapunzel syndrome – SBO due to trichobezoar extension into small bowel lumen www.ispub.com/.../ijs/vol14n2/rapunzel.xml www.learningradiology.com/.../bezoarcorrect.htm

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Mladen Nisavic, MS III Gillian Lieberman, MD

Summary: •

Foreign object ingestion is an uncommon, but devastating presentation of patients with severe borderline personality disorder.

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These patients are typically “complicated” patients and tend to be refractory to behavioral or pharmacologic treatment options. Most of them will repeat the self-harming behavior soon after they are discharged from the hospital

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While commonly patients ingest objects to obtain attention (or medical care), it is not uncommon that serious complications or even death ensue.

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Radiologic imaging is an essential component of medical management of these patients. They typically require numerous (serial) KUBs and chest X-rays to evaluate for any significant pathology until the foreign bodies are cleared.

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Surgery is only recommended in the setting of significant pathology (e.g. obstruction or perforation). 26

Mladen Nisavic, MS III Gillian Lieberman, MD

References: • • • • •

• •

• • • • •

Carr JR, Sholevar EH, Baron DA (2006) Trichotillomania and trichobezoar; a clinical practice insight with report of illustrative case. J Am Osteopath Assoc. 2006 Nov; 106(11):647-52 Gitlin DF, Caplan JP, Rogers MP, Avni-Baron O, Braun I, Barsky AJ (2007) Foreign-body ingestion in patients with personality disorders. Psychosomatics. 2007 Mar-Apr;48(2):162-6. Hunt I, Hartley S, Alwahab Y, Birkill GJ. (2007) Aortoesophageal perforation following ingestion of razorblades with massive haemothorax. Eur J Cardiothorac Surg. 2007 May;31(5):946-8. James AH, Allen-Mersh TG (1982) Recognition and management of patients who repeatedly swallow foreign bodies. J R Soc Med 1982; 75:107–110 Katsinelos P, Kontouras J, Paroutoglou G, Zavos C, Mimidis K, Cgatzimavroudis G. (2006) Endoscopic techniques and management of foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: a retrospective analysis of 139 cases. J Clin Gastroenterol. 2006 Oct;40(9):784-9. Levine MJ, Jacob H, Rubin M. (1984) Battery ingestion: a potential form of alkaline injury to the gastrointestinal tract. Ann Emerg Med. 1984 Feb;13(2):143-5. Perseius KI, Ojehagen A, Ekdahl S, et al (2003) Treatment of suicidal and deliberate self-harming patients with borderline personality disorder using dialectical behavioral therapy: the patients’ and the therapists’ perceptions. Arch Psychiatr Nurs 2003; 17:218–227 Skodol AW, Johnson JG, Cohen P, Sneed JR, Crawford TN. (2007) Personality disorder and impaired functioning from adolescence to adulthood. Br J Psychiatry. 2007 May;190:415-20. Smith MT, Wong RK (2006) Esophageal foreign bodies: types and techniques for removal. Curr Treat Options Gastroenterol. 2006 Feb;9(1):75-84. Soong CV, Harvey C, Doherty M (1990) Self-mutilating behavior and deliberate ingestion of foreign bodies. Ulster Med J 1990; 59:213–216 Villalba R, Harrington CJ (2005) Repetitive self-injurious behavior: a neuropsychiatric perspective and review of pharmacologic treatments. Semin Clin Neuropsychiatry 2000; 5:215–226 Williams C, McHenry CR (2004) Unrecognized foreign body ingestion: an unusual cause for abdominal pain in a healthy adult. Am Surg. 2004 Nov;70(11):982-4.

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Mladen Nisavic, MS III Gillian Lieberman, MD

Acknowledgements: BIDMC Radiology Department: • Gillian Lieberman, MD • Maria Levantakis • Staff/Residents • Larry Barbaras BIDMC Psychiatry Department: • Tina Lusignolo, MD • Todd Eisenberg, MD

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