Foreign body in the gastrointestinal tract as a result of suicide attempt: a case report

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INTRODUCTION

In the literature, people with mental illness are reported to take various substances and chemicals to commit suicide [1, 2, 3]. Such suicidal behavior is also observed among prisoners and servicemen [4, 5, 6, 7]. Usually, when people with mental illness commit suicide by ingesting a foreign object, they swallow cutting and piercing objects. From our experience, foreign bodies, such as sewing needles, nails, metal pieces of iron, stones, and various objects, are commonly found in the possession of patients with the intent to commit suicide. However, the consumption of large nails weighing up to 1 kg for suicide purposes has not been reported yet. Our observation was interesting because the patient, a 21-year-old soldier, swallowed 32 pieces 15-cm iron nails in 1 month, which passed through the esophagus without complications and accumulated in the gastrointestinal tract.

CASE PRESENTATION

Patient N., a 21-year-old soldier, has been serving in the armed forces for 4 months. He had no records of hereditary mental illness. The initial development period was weak. At a young age, he lagged behind his peers in psychophysical development. He was always under the protection and control of his parents. He was not able to master the curriculum in high school, and frequent behavioural disorders were noted. Later, in the boarding school, he was in a class for mentally retarded children. However, he was also expelled from there for constantly quarrelling, breaking windows, beating his peers, and violating discipline rules. He has never been examined or treated in any medical institution before. During the call-up for military service, he was examined by a commission of military doctors in the mobilization department and found suitable for military service. The service records of the military unit revealed that from the first day of his service, he showed himself as an undisciplined, incompetent, untidy, and negligent soldier. He evaded the execution of instructions and tasks under various excuses. Unable to bear the hardships and difficulties of military service, he began to swallow large numbers of nails to commit suicide within a month. Finally, he told his commander that he had swallowed many nails and could not stand the pain anymore. In this regard, he was sent to the medical battalion for examination, treatment, and determination of fitness for military service. After a day of examination, he was sent to the Main Clinical Hospital of the Armed Forces for a psychiatric examination. During the examination in the admission department of the hospital, through a radiological observation, about 20 foreign bodies and nails were found in his stomach. He was hospitalized in the department of joint trauma surgery, and on August 17, 2011, he underwent “laparotomy, gastrotomy, and removal of foreign bodies (32 nails).” He was examined by a psychiatrist for his suicidal ideation and was transferred to a psychiatric department on suspicion of mental retardation and to prevent another suicide attempt. While being examined and treated in the psychiatric ward, he was always quite sluggish, ridiculed for his inappropriate speech and actions, and sometimes cried or laughed for no reason. During the examination and treatment, he was examined by a professor-psychiatrist and diagnosed with “F70.1 Mild mental subnormality with expressive behavioral disorders.” The diagnosis was made according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision.

Objective examination data

He had normal body structure and adequate nutrition. The subcutaneous fat layer was sufficiently developed. The skin and visible mucous membranes were normal in color, with a hardened skin scar ≈20.0 × 0.8 cm on a white line, was found in the anterior wall of the abdomen. Peripheral lymph nodes were not enlarged, mobile, and painless. During auscultation in the lungs, vesicular breathing was heard, and there was no wheezing. Heart tones were clear and rhythmic. Blood pressure was 110/70 mm.cv.st. The pulse was full, rhythmic, and beating 78 beats per min. The abdomen was soft and painless. The liver and spleen were not enlarged. Beating on the lumbar region was painless on both sides. Urine and feces were normal. Neurological condition: Consciousness was clear. The cranial nerves were normal. No organic changes in the central nervous system were observed. Muscle–tendon reflexes are in moderate arousal; D = S. No pathological reflexes. He was stable in Romberg’s condition; tremors of elongated fingers and eyelids are observed. Distal hyperhidrosis and persistent red dermographism were observed. Mental condition: oriented in space, situation, time and own personality. He began a conversation in a tense manner, laughing out loud, and making inappropriate gestures. He gave short, naive answers to questions with excitement and panic. After a few sentences, he cried. “I have been sick since I was a child. I was always scared, so I was always kept at home, not allowed anywhere. I do not know what I do. I also have no idea I do in the military!” Perceptual disturbances and delusions were not noted. Emotions were impoverished. He did not have abstract and logical thinking. He did not understand the literal meaning of proverbs and sayings. During the conversation, his mood often changes, either looking pessimistic, hopeless, helpless, calm, or restrained. He cannot read and write. He performed simple calculation operations with difficulty. He had little knowledge and vocabulary, explained simple generalizations with help, and tended to think concretely. The scope of interest was limited and needs have been simplified. His memory was not damaged. Sleep was superficial, and food was enough.

Results of special examinations

X-ray imaging data of the abdominal cavity on August 15, 2011, was as follows: “200 mL of barium solution was given per-os: foreign bodies ≈20 pieces ~ 15 cm long nails are located in the stomach” (Figs. 1 and 2).

Fig. 1. X-ray of the abdomen (front projection — military uniform).

Fig. 2. X-ray of the abdomen (front projection).

General analysis of the blood and urine, blood sugar measurement, immunological analysis of the blood, fluorography of thoracic organs, X-ray imaging of the skull, and electrocardiography findings were normal. In the radiography of the abdominal cavity conducted on August 19, 2011, no foreign bodies or nails were found in the abdomen. The psychologist’s diagnosis was mild subnormal IQ-68.

Psychiatric diagnosis: F70.1 Mild mental subnormality with expressive behavioral disorders.

Surgical diagnosis: Laparotomy, gastrotomy, and removal of foreign bodies (32 nails) in postoperative condition (Fig. 3).

Fig. 3. Metal nails (32 pcs.) taken out during the operation.

According to the decision of the military-medical commission, Patient N. was considered unfit for military service because of his mental illness and was advised to use preventive treatment in an outpatient setting by registering with a psychiatrist in the area where he lives.

DISCUSSION

Generally, suicide disorders at a young age occur as a direct result of a situation (mental trauma) and therefore resemble a “short-circuit” reaction. Suicidal behavior is often caused by real reasons. Increasing events of desperate behavior, inability to find a way out of the crisis, certainty that the problem cannot be solved, and subjective assessment of the conflict situation can lead to suicidal behavior. Gregory et al. theorized about adolescent self-harm motivation. Self-harming behavior is used as a technique of conquering bad feelings or stress when individuals are unable to cope appropriately, which he referred to as “magic thinking” [9]. Suicide cases among people with mental illness mainly occur in the presence of conditions such as depression, paranoid, and hallucinatory-paranoid [1].

Even in the presence of mental pathologies, regardless of the severity of the condition, suicide cases are not necessarily related to disease symptoms. Suicidal behavior is most common during periods of high and debilitating depression (especially after discharge from the hospital). Generally, suicides occurred in the early disease stages, as a result of the presence of a stereotyped personality, or in a state of remission, i.e., when the personality remains the same; thus, the individual expresses his/her attitude to external influences almost as a healthy person. Such suicides are more likely to be caused by pathological symptoms.

Our experience and literature review show that most foreign bodies (67%–80%) measuring 2.5–6 cm are excreted naturally from the digestive tract within a week [10]. However, depending on the size and type of the foreign body, surgical intervention is required. Studies have shown that patients with mental illness repeatedly swallow foreign bodies [11, 12]; however, it is very rare for a person with mental illness to ingest foreign objects consecutively for a month.

CONCLUSIONS

From our examinations and observations, for people with mental illness, the size and weight of foreign bodies do not matter when ingested to commit suicide. The patient under our supervision said, “I thought the nails were big, and they would kill me quickly.” From our experience, people who ingested large numbers of objects to commit suicide have unsatisfactory intellectual level, and their actions are the product of primitive thinking.

ADDITIONAL INFORMATION

Funding source. This article was not supported by any external sources of funding.

Competing interests. The author declares he has no competing interests.

Consent for publication. Written consent was obtained from the patient for publication of relevant medical information and all of accompanying images within the manuscript.

About the authors

Elshad S. Mehdiyev

Author for correspondence.
Email: elshadmehdiyev@yahoo.com
ORCID iD: 0000-0001-8725-9143
SPIN-code: 4575-8393
Scopus Author ID: 751418

MD, Cand. Sci. (Med.)

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2. Fig. 1. X-ray of the abdomen (front projection — military uniform).

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3. Fig. 2. X-ray of the abdomen (front projection).

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4. Fig. 3. Metal nails (32 pcs.) taken out during the operation.

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