A Rare Cause of Sigmoid Obstruction in a 77-Year-Old Patient

Table of Contents

A 77-year-old man presented with a 5-day history of constipation and cramp-like lower abdominal pain. Multiple colonic diverticula had been diagnosed on a colonoscopic examination in 1994. On admission, striking tenderness of the sigmoid colon was observed, but no signs of peritoneal inflammation, and on rectal examination the ampulla was empty of feces. There was no fever, and the red and white blood cell counts and C-reactive protein were normal. On transabdominal ultrasonography, adequate visualization of the sigmoid colon was not possible due to intervening gas and fat, and the abdominal radiograph showed colonic distension with gas and feces, but without air-fluid levels. In order to clarify the cause of the suspected sigmoid obstruction, it was decided to carry out a sigmoidoscopy after preparation with several large-volume enemas. The sigmoid colon was easily reached, and a large undamaged blister-wrapped tablet of tamsulosin (Omnic) was found firmly impacted in a swollen sigmoid segment with multiple diverticula (Figure [1]). The foreign body was cautiously crumpled, mobilized, and extracted using a stone retrieval basket. On repeat sigmoidoscopy, a fissural ulceration surrounded by edema was visualized at the site of impaction (Figure [2]). The patient remained pain-free after the investigation, and further defecation was effective. At a colonoscopy examination 4weeks later, it was observed that the ulceration had healed, and the endoscopic findings were normal apart from extended sigmoid diverticular disease.

Figure 1 Blister-wrapped tablet of Omnic 0.4, with sharp edges, impacted in a swollen segment of the sigmoid colon.

Figure 2 Repeat sigmoidoscopy after removal of the foreign body, with fissural ulceration at the impaction site.

If possible, large, sharp foreign bodies ingested orally should be removed from the upper gastrointestinal tract endoscopically. After passing the stomach, the chances of such foreign bodies causing perforation - usually at the ileocecal valve - are estimated at between 15 % and 20 % [1] [2]. Few case reports on intestinal complications after ingestion of a blister-wrapped tablet have been described [3] [4]. We have seen several patients with blister-wrapped tablet impaction in the esophagus and clinical symptoms of sudden severe dysphagia. This is the first clinically overt case in our experience in which this type of foreign body passed spontaneously to the large bowel and impacted in the sigmoid colon.

Tamsulosin is an α₁-receptor antagonist that is prescribed in the treatment of benign prostatic hyperplasia [5]. The drug sometimes causes gastrointestinal complaints, including constipation, but for other reasons than in the case reported here. Physicians should be aware that patients sometimes need to be reminded to remove tablets from blister packages before ingestion.

References

• 1 Chung R S. Removal of foreign bodies. In: Chung RS (ed). Therapeutic endoscopy in gastrointestinal surgery.  Edinburgh; Churchill Livingstone 1987: 227-242
• 2 Webb W. Management of foreign bodies in the upper gastrointestinal tract.  Gastroenterology. 1988;  94 204-216
• 3 Norstein J, Krajci P, Bergan A. et al . Intestinal perforation after ingestion of a blister-wrapped tablet.  Lancet. 1996;  346 1308
• 4 Gupta V, Manikyam S R, Gupta R. et al . Pelvic abscess after ingestion of blister-wrapped tablet.  Am J Gastroenterol. 2002;  97 2142-2143
• 5 Wilt T J, MacDonald R, Nelson D. Tamsulosin for treating lower urinary tract symptoms compatible with benign prostatic obstruction: a systematic review of efficacy and adverse effects.  J Urol. 2002;  167 177-183