The management of bullet ingestion in a child

Öz

To the Editor Ingestion of foreign bodies is most commonly observed in children aged between 6 months and 3 years Generally the children in this age group put foreign bodies into their mouths to know them Foreign bodies most commonly lead to obstruction at the cricopharyngeal muscle level in the 1 3 middle part of the esophagus in the lower esophageal sphincter in the pylor and in the ileocecal valve 1 The most commonly ingested foreign bodies include coins toy parts fish bone pin and batteries 1 2 Foreign bodies pass trough the gastrointestinal system spontenously with a rate of 80 90 10 20 of foreign bodies are removed endoscopically and only 1 need surgical intervention 3 In this article ingestion of bullet which is an unusual foreign body was presented and treatment approach was discussed A 14 month old female patient presented to our outpatient clinic with a complaint of ingesting a bullet approximatley 3 hours ago Her vital signs were found to be normal It was learned from the family that the child ingested the bullet while playing in the street Physical examination was found to be normal White blood cell count was found to be 11 000 mm3 and the other laboratory findings were within normal limits Abdominal pain and vomiting were not observed in the follow up Standing abdominal x ray revealed that the bullet was at the level of the jejenum No pathology was found in the patient who was evaluated by the division of Hematology in terms of hemolytic anemia Serum and 24 hour urine lead levels were found to be normal Daily standing abdominal x ray follow up revealed that the bullet progressed in the intestines In the 56th hour the bullet exited from the anus spontaneously Similar to our patient who found and ingested a bullet while playing in the street a child who ingested a piece of lead while eating meat was reported in the literature 4 In contrast to our patient the piece of lead was settled in the appendix and preventive appendectomy was performed against potential lead poisoning and appendicitis In our patient no surgical intervention was needed since blood and urine lead levels and abdominal examination were found to be normal Lead poisoning is a condition which has been known for a long time and widely described in children It may lead to symtomps and signs including abdominal pain vomiting constipation joint pain headache increased blood pressure malaise and loss of appetite 5 The time from wounding by firearms to onset of symptoms has been reported to range between 2 days and 52 years 6 Serum lead level should be measured regularly at the first admission to the hospital and before discharge in any patient who has a piece of lead in his her body In patients who have bullets in their body as observed in woundings by firearms serum lead levels should be monitored monthly in the first three months and yearly thereafter 7 In our patient monitoring of this unusual foreign body was done by observing the clinical symptoms of lead poisoning and serum and urine lead levels Since the bullet exited from the body monitoring of serum lead levels was not needed after discharge Conclusively ingestion of bullet should be closely monitored clinically and by laboratory tests in terms of lead poisoning In addition it would be more appropriate to follow up the patients before the signs and symptoms of lead poisoning develop instead of urgent surgery

Anahtar Kelimeler

• -

Mermi yutan bir çocuğa yaklaşım

Öz

Yabancı cisimlerin ağızdan alımına en sık altı ay ile üç yaş arasındaki çocuklarda rastlanır Genellikle bu yaş aralığındaki çocuklar ellerine geçen yabancı cisimleri tanımak için ağızlarına götürürler Yabancı cisimlerin en sık tıkanıklığa sebep olduğu alanlar krikofarengeal adele seviyesi özofagusun 1 3 orta kısmı alt özofajeal sfinkter pilor ve ileoçekal valvdir 1 En fazla alınan yabancı cisimler madeni para oyuncak parçaları balık kemiği iğne ve pildir 1 2 Yabancı cisimler 80 90 sindirim sistemini kendiliğinden geçerler Cisimlerin 10 20 rsquo;si endoskopik olarak çıkarılırken sadece 1 rsquo;lik bir kısmı cerrahi müdahale gerektirir 3 Bu yazıda alışılmadık bir yabancı cisim olan merminin ağızdan alımı sunularak tedavi yaklaşımı tartışılmıştır Otuz dört aylık kız çocuğu polikliniğimize yaklaşık üç saat önce mermi yutma yakınması ile başvurdu Yaşamsal bulguları normaldi Aileden alınan öyküde çocuklarının mermiyi sokakta oynarken yuttuğu öğrenildi Fiziki muayene normaldi Lökosit sayısı 11 000 mm3 olup diğer laboratuvar bulguları normal sınırlardaydı İzlemlerinde karın ağrısı ve kusma olmadı Ayakta direkt karın grafisinde kurşunun jejenum seviyesinde olduğu saptandı Hemolitik anemi açısından çocuk hematoloji bölümü tarafından değerlendirilen hastada patoloji saptanmadı Serum ve 24 saatlik idrar kurşun düzeyleri normaldi Günlük ayakta direkt karın grafisi izleminde merminin bağırsaklarda ilerlediği izlendi Elli altıncı saatte kurşun makattan kendiliğinden çıktı Sokakta oyun oynarken mermi bulup yutan olgumuza benzer şekilde literatürde et yerken kurşun parçası yutan bir çocuk bildirilmiştir 4 Bizim olgumuzdan farklı olarak kurşun parçasının apendikse yerleştiği bu olguda olası kurşun zehirlenmesi ve apandisit risklerine karşı koruma amaçlı appendektomi yapılmıştır.

Anahtar Kelimeler

• Mermi
• yutan
• çocuğa

Kaynakça

1. Denney W, Ahmad N, Dillard B, Nowicki MJ. Children will eat the strangest things: a 10-year retrospective analysis of foreign body and caustic ingestions from a single academic center. Pediatr Emerg Care 2012; 28(8): 731-4. 182 Türk Ped Arş 2013; 181-2 Turk Arch Ped 2013; 181-2 Sarsu ve ark. Mermi yutulması / Bullet ingestion
2. Pokharel R, Adhikari P, Bhusal CL, Guragain RP. Oesophageal foreign bodies in children. JNMA J Nepal Med Assoc 2008; 47(172): 186-8.
3. Antoniou D, Christopoulos-Geroulanos G. Management of foreign body ingestion and food bolus impaction in children: a retrospective analysis of 675 cases. Turk J Pediatr 2011; 53(4): 381-7.
4. Mincheff TV. Bullet fragment within the appendix: a case report. J S C Med Assoc 2004; 100(10): 270-3.