Retrieval of a bread bag clip from the duodenum

A 73-year-old woman presented with iron deficiency anemia and melena. Biochemical parameters revealed a hemoglobin of 77 g/L and urea 8.5 mmol/L with normal renal indices. She was transfused with 2 units of red blood cells. Gastroscopy revealed a bread clip embedded in D1 (showing the date Friday, 13 April; [Fig. 1]), pinching the distal and proximal duodenal roof fold and dangling like an earring. Attempts to remove the clip by crushing with grasping forceps, cutting with a needle-knife device, and snapping with snare were unsuccessful. A gastric band cutter (Endotherapeutics, Sydney, Australia) was employed endoscopically. The cutting wire was threaded between the bread clip and the duodenum ([Fig. 2]), and the free end was retrieved and locked into the racheting device, forming a loop. Tightening of the loop resulted in the wire snapping the clip, which was then retrieved orally ([Fig. 3]).

Fig. 1 Bread clip embedded in first part of duodenum in a 73-year-old woman presented with iron deficiency anemia and melena. There is linear erosion on the posterior wall.

Fig. 2 The cutting wire was fed down the duodenum.

Fig. 3 The bread clip was divided and then retrieved orally.

Only 21 cases of bread clip ingestion have been reported since 1975. Most cases present as small-bowel perforation requiring bowel resection [1]. Bread clips are made of plastic and are therefore nondegradable. With an aging population, we postulate that such cases will be increasingly seen [2]. The shape of the clip results in a traplike effect, which prevents easy removal once it is embedded [3]. Endoscopic removal of embedded foreign bodies can require taking a unique approach. This is the first reported case of the use of a gastric band cutter to divide an embedded foreign body followed by successful retrieval.

Endoscopy_UCTN_Code_TTT_1AO_2AL

Competing interests: None

• References

• 1 Newell KJ, Taylor B, Walton JC et al. Plastic bread-bag clips in the gastrointestinal tract: report of 5 cases and review of the literature. CMAJ 2000; 162: 527-529
• 2 Beer T. Fatalities from bread tag ingestion. Med J Aust 2002; 176: 506
• 3 Tang A, Kong A, Walsh D et al. Small bowel perforation due to a plastic bread bag clip: The case for clip redesign. ANZ J Surg 2005; 75: 360-362