Ingestion of several rubber gloves: A case report on Pica syndrome

Abstract

Key Clinical Message

After ingestion rubber gloves harden and can produce dangerous complications. Therefore the choice of treatment is of utmost importance. Aside from a surgical approach, endoscopy should also be considered as a treatment option on a case‐to‐case basis or if not applicable as a useful diagnostic tool.

INTRODUCTION

Pica, also known as allotriophagia, derives from the Latin word Pica Pica, meaning magpie, and was first reported by Hippocrates in the fourth century BC, describing the eating of inorganic or nonnutritive substances.^1,2 As ingesting inorganic substances is considered developmentally appropriate up to the age of 18 months according to Freud's psychoanalytic oral stage, Pica disorder can only be diagnosed as such in older children and adults.^1,3 While the etiology remains unclear to this day, Pica disorder has been linked to various other illnesses and disorders as well as pregnancy.^1,4,5 Comorbidities have been found with major psychological disorders such as psychosis, obsessive–compulsive disorder as well developmental and neurodegenerative disorders, and nutrient deficiencies.^1,5 In childhood, autism spectrum disorders and intellectual or developmental disabilities are often reported comorbidities for Pica.^1,5

The ingested substances vary on a case-to-case base. To accurately describe these different subtypes, several descriptive terms have been coined, such as acuphagia, the ingestion of sharp objects, coprophagia, eating feces, or more commonly trichophagia, which describes the ingestion of wool or hair.^1,3

The effects on the affected individual's body are dangerous and potentially lethal as complications include bowel obstructions, lead poisoning, perforation, and bezoars.¹ Other complications are for example dental erosions and iron deficiency.¹

For many of the abovementioned complications the treatment of choice is surgical in nature. To prevent future complications, treatment of the underlying diagnosis of Pica is also highly important. In cases where a nutrient deficiency has been reported, Pica can sometimes be cured by treating the deficiency.³ However, there are also cases where on discontinuation of treatment for the nutrient deficiency, Pica has reoccurred and a causal relationship between nutrient deficiencies and Pica thus seemed unlikely.^1,4 Other treatment options include applied behavioral analysis therapy (ABA)¹ or preventative measures taken by parents or caregivers.⁵ Pharmacological trials with selective serotonin reuptake inhibitors (SSRIs) such as sertraline have shown variable results.^1,6

Rubber gloves when ingested harden and sometimes form hard edges.^7–10 Due to this the current literature rules out the possibility of an endoscopic removal.^7–9 The here presented case is to our knowledge the first where endoscopic removal was successfully performed. Therefore it demonstrates a new possibility in the treatment of this rare Pica subtype.

CASE HISTORY

We present the case of a 16-year-old male patient with autism spectrum disorder. As a Ukrainian refugee, the patient only understands Russian but is nonverbal and resides in a facility for refugees with disabilities. He had been living in Germany for the last 6 months at the time of admission to our hospital. No regular or current medication was reported.

The patient presented to our emergency department at around 1 pm accompanied by a caretaker. For the last two and a half days, he had been vomiting bilious. Pica syndrome was suspected, as the patient also regurgitated pieces of string and undefined small plastic objects. The last meal consisting of a few pieces of chocolate at around 9:30 am had not been tolerated as he immediately vomited. The intake of liquids had not been affected. The patient had no known allergies and underwent no prior surgeries. Prior Pica-related incidents have not been reported.

On admission, the patient was in a reduced general but good nutritional condition. The physical examination showed no reportable abnormalities. Especially the abdominal examination produced no finding: on manual palpation the abdomen was soft, the auscultation revealed regular peristalsis over all four quadrants.

METHODS (DIFFERENTIAL DIAGNOSIS, INVESTIGATIONS, AND TREATMENT)

Because of the personal history of regurgitating foreign objects, the ingestion of nonedible objects was most likely the cause of the patient's current symptoms. A diagnostic esophagogastroduodenoscopy was performed to confirm the diagnosis and to simultaneously remove any such object. During the procedure, a foreign object was observed in the transition from gastric fundus to corpus, which on first sight appeared to be a piece of plastic. On further observation, a disfigured medical or rubber glove used in the intrahospital setting was identified (see Figure 1). Hereafter, removal of the glove by endoscopic grasping forceps was attempted (see Figure 2). The glove was successfully transported from the stomach to the esophagus, but further removal proved challenging as passage over the cricopharyngeal constriction was not possible without excessive force, as the material seemed to have hardened and showed a plaster-like consistency. Because of the complicated situation for removal, the decision was made to intubate the patient to secure the airway. Afterward muscle relaxation via rocuronium (0,9 mg/kg) was administered to reduce the muscle tone of the striated muscle. A careful dislodgement of the cured glove to the esophagus entrance was carried out, so that it became visible via the laryngoscope, while the airway was splinted by an endotracheal tube. Hereafter the glove was successfully removed with the aid of a Magill's forceps. A final examination of the stomach and duodenum was performed. Superficial mucosal erosions were discovered in the proximal stomach. We found no ulceration or further damage. The patient received 2 mg/kg pantoprazol intravenously and was discharged in good general condition on the same day after several hours of surveillance.

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After removal we tried to open up the disfigured glove, to prove that it was completely removed. By carefully pulling the structure apart with medical tweezers, the original form could be surmised (see Figures 3 and 4). No pieces were missing. The gloves consistency remained cured and formed hard, almost sharp edges.

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Two days later, the patient was readmitted to our emergency department. He presented with vomiting and abdominal pain which occurred anew after the initial discharge following the removal of the rubber glove. Neither food nor liquid intake was tolerated at this point and his general condition continued to worsen. A de novo ingestion of foreign objects was unlikely based on the patient's history as he had been observed one-to-one since his hospital release 2 days prior. The physical examination revealed reduced or sparse bowel sounds suggesting an ileus. An ultrasound as well as an x-ray of the abdomen were performed, revealing radiological signs of an ileus of the small bowels. The ultrasound additionally showed a foreign object in the right abdomen not visible on the x-ray. As the x-ray showed a considerable amount of stool in the colon, a laxative enema, intravenous fluids, and analgesics were administered. Hereafter the vomiting ceased and the pain got significantly better, therefore no further diagnostics were performed at this time and we continued to monitor the patient closely.

The next day (3 days after the initial visit), the vomiting restarted. During this time period the patient was fasting; he received sufficient fluid replacement intravenously (i.v.). Another ultrasound was performed, showing no considerable change.

On the following day (4 days after the initial visit), the patient complained of increasing abdominal pain. We performed a computer tomography scan (CT), revealing a foreign object measuring 4.1 × 2.8 × 5.4 cm partially filled with air in the upper left abdomen (See Figures 5 and 6), blocking the intestinal passage presumably at the jejunum. A diagnostic laparoscopy was performed revealing an unidentifiable foreign object. Because of the size of the foreign object, the incision of the skin in the upper left abdomen had to be widened 8 cm on both sides to perform a mini-laparotomy. Removal of a bezoar later identified as at least one rubber glove was accomplished (see Figure 7). The exact number of gloves ingested could not be determined as the bezoar was completely cured and formed hard edges. During the curing of the material, air was trapped inside the gloves, most likely further expanding the size of the bezoar and impeding the removal.

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The patient received weight-adapted perioperative antibiotic therapy with ceftriaxone and metronidazole over 5 days. A step-by-step return to a normal diet was well tolerated and the patient was released in good general condition 10 days postoperative.

CONCLUSIONS AND RESULTS (OUTCOME AND FOLLOW-UP)

In the following month, two admissions of our patient to our emergency department took place. Neither one required surgical intervention. The first of these admissions was due to the observed ingestion of a flower made of cloth. As the patient was asymptomatic, no further action was required. The second admission was due to regurgitation of several woolen strings as well as a refusal to eat. An x-ray was performed showing no sign of an ileus. The patient was given fluids intravenously and an abstinence of food was prescribed. As the patient's general condition improved significantly under these measures, no endoscopy was performed and the patient was released 2 days later.

Seven months after the initial admission the patient presented anew to our emergency department having swallowed 20 cm of masking tape. As he developed no symptoms, the patient was released in his caregivers care for further observation.

About a year after the initial ingestion he was referred to us by his attending physician. In the 3 weeks leading up to the consultation, the patient's attachment figure had been on holiday and a noticeable change in character took place. As an abdominal cause was suspected, an abdominal ultrasound was performed to rule out inflammatory changes to the bowels. No abnormalities were found. After this the patient was unfortunately lost to follow-up.

To conclude the patient suffered no long-term effects resulting from the first or any other here described Pica-related episodes until he was lost to follow-up. The facility where he resides was advised of the diagnosis of Pica syndrome and necessary precautions. While a one-to-one care has been established after the patient's first Pica-related episode, this can only be guaranteed while in his living facility. While at school no one-to-one care can be assured.

DISCUSSION

Pica is a well-reported although not well-understood disease that has been documented for centuries. Different ingested substances require different treatment approaches and complications vary. Yet the change of consistency of the ingested rubber gloves, that cured when exposed to the intestinal system, is remarkable and in our opinion worthy of communication. The soft and pliable rubber gloves hardened and formed bezoars, making the removal a lot more difficult than expected and increasing the possibility of complications.

It is known that the low pH of gastric acid has effects not only on ingested food, but also on other nonorganic substances that it comes in contact with.¹¹ This effect is vital for the understanding of Pica complications but also in other medical specialities such as dentistry where gastric acid causes demineralization of dental hard tissues and decreases the hardness and surface texture of composite resins.¹¹

It is also not unheard of, that rubber gloves when ingested harden and form bezoars. Unbeknownst to us at the time of admission of our patient, few cases have been reported over the years where this phenomenon has been documented.^7–10 Yet the question as to why rubber gloves change in the here described way has not yet been sufficiently answered. It has been suggested that the vinyl or more accurately the polyvinyl chloride undergoes a chemical transformation when exposed to gastric acid.⁹ A German study was performed in 1977 called “Endangering of Health by Ingestion of Soft-Polyvinylchloride”.¹² In this study, plastic objects containing soft polyvinylchloride were placed in the stomach of pigs and left there for up to 102 days.¹² The results show us that after spending time in the pigs's stomach, the plastic contained significantly less softening agents then before.¹² The retrieved object was cured in the process.¹² This leads us to the conclusion that the gastric acid in our patients stomach dissolved out the softening agents contained in the rubber glove, forming the hardened object we ultimately retrieved.

In cases such as the one described in our case report, physicians need to apply a risk–benefit analysis before choosing a treatment regimen. If a rubber glove is ingested it should always be removed as it should be considered as a possibly sharp object and spontaneous passage is unlikely.^13,14

In general, endoscopic removal is a safe method to remove gastric foreign bodies and should always be considered.¹⁵ Yalçin et al. showed a successful extraction rate in 68% of patients and a need for secondary surgery only in 9.5% of cases.¹⁵ Webb even showed a 98.8% succession rate of endoscopy.¹³ However this information can not directly be applied to ingestion of rubber gloves.

To our best knowledge no other case showed a successful endoscopic removal.^7–9 As in these cases endoscopic removal was highly discouraged,^7–9 our treatment plan might have differed in view of this discussion. It is possible that endoscopic removal in our case was only achievable as the glove was located in the transition from gastric fundus to corpus and had not yet been transported any further. We acknowledge, that the risk of further damage is a strong risk factor to endoscopic removal, yet we also asses that under certain conditions where for example the glove or gloves are not yet completely cured, therapeutic endoscopy should not be discarded completely, as the risk of surgical intervention is also considerable.

In addition, endoscopy remains a useful and necessary diagnostic tool,^7,9 as not all patients who ingest foreign objects can accurately tell what has been ingested or can understand the difference between edible and inedible objects.⁵ In our case, the patient was nonverbal and the ingestion had not been observed. Imaging technics were also flawed in this case, for the presence of a foreign body was detectable but not the nature of it. In those cases, endoscopy is the preferred diagnostically choice as it is less invasive as a surgical approach.^7,9

Furthermore Webb states that secondary surgery should not be “considered defeat […] for this is sometimes the safest means”.¹³ If these points are considered, we conclude endoscopy to be a viable first-line therapy even in the case of rubber glove ingestion.

While it is important to treat the complications of Pica syndrome it is also important to consider a more holistic approach to limit future necessity of object removal. It is therefore highly important to thoroughly educate patients and their caregivers about the illness and if possible restrict access to known ingested objects.^5,16 In addition to that behavioral therapy should also be considered.⁵

In summary, we demonstrated in our case report that medical or rubber gloves show a significant risk when ingested. The material, which seems harmless as it is soft and pliable becomes hard and hazardous when it comes in contact with gastric acid. It is therefore vital to know the nature of an ingested object before attempting to remove it.

AUTHOR CONTRIBUTIONS

Sarah Winterland: Conceptualization; resources; writing – original draft; writing – review and editing. Jeremy Schmidt: Writing – review and editing. Dennis Nordhoff: Writing – review and editing. Winfried Barthlen: Writing – review and editing. Eckard Hamelmann: Writing – review and editing. Sebastian Gaus: Supervision; writing – review and editing.

FUNDING INFORMATION

We acknowledge support for the publication costs by the Open Access Publication Fund of Bielefeld University and the Deutsche Forschungsgemeinschaft (DFG).

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no competing interests.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

CONSENT

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

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