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A 30 year-old man with a history of human immunodeficiency virus (HIV) infection on highly active antiretroviral therapy (HAART) and with polysubstance abuse presented to the emergency department complaining of 2 hours of diffuse abdominal pain. The pain began after being pulled over by the police for an unspecified traffic violation. In his possession was a crack pipe, which he swallowed to avoid detection by police.
On initial presentation, vital signs were stable. The patient was in moderate distress and complained of a diffuse, crampy abdominal pain and mild odynophagia without dysphagia. He denied chest pain or palpitations and was able to tolerate his oral secretions. Diffuse abdominal tenderness to moderate palpation was present without rebound tenderness or guarding. Bowel sounds were normal and present in all 4 quadrants. The remainder of the physical examination was normal; however, the patient became lethargic after the initial examination and had likely ingested a previously prescribed oral benzodiazepine.
Initial laboratory results, including a complete blood count and comprehensive metabolic panel, were within normal limits. An electrocardiograph showed normal sinus rhythm without ST changes. An abdominal radiograph confirmed a radiopaque tube in the stomach (Figure A). The tube measured approximately 10 × 1 cm and contained a circular, radiopaque material within its lumen. No other foreign bodies were visualized on chest or abdominal radiographs, and there was no radiographic evidence of perforation.
Should this ingested foreign body be removed endoscopically?
After discussing the case with the general surgery service, the decision to attempt the endoscopic removal of the crack pipe was based on its jagged appearance by abdominal radiograph and concern for imminent perforation. The patient’s family was informed of the potential risks of the procedure, including the inability to retrieve the foreign body, the possibility of esophageal and/or gastric perforation, and the danger of aspiration of glass, metal, and/or cocaine.
The patient was intubated, and a gastric overtube was passed into the stomach. Esophagogastroduodenoscopy revealed a glass tube lying in the gastric fundus (Figure B), parallel to the gastric overtube (Figure C). Initial attempts at grasping the pipe directly with forceps were unsuccessful. To securely grasp the pipe, the pipe was repositioned in the gastric body with a loop snare. The shaft of the forceps was positioned within the lumen of the pipe, and the forceps were kept open to secure the forceps against the walls of the pipe. The crack pipe was removed from the patient and seemed to be largely intact (Figure D). On repeat endoscopic inspection, a small glass shard was found in the gastric body and was removed with forceps. No other foreign bodies were seen in the esophagus, stomach, or examined duodenum. The patient was observed overnight and discharged the next day.
Our case highlights a unique set of clinical and logistical considerations for the management of an unusual foreign body ingestion. The endoscopy was performed under general anesthesia for both airway protection and to facilitate the use of the gastric overtube to minimize the risk of esophageal or oropharyngeal trauma. The contents of the crack pipe were equally significant, considering the mucosal trauma that could result from the metal screen filter1 as well as the toxicologic effects of absorbed residual crack cocaine.2 The ability to secure a slender glass tube containing jagged edges was not straightforward. In our case, multiple attempts at directly grasping the end of the crack pipe with forceps or the glass stem with a snare were unsuccessful. Ultimately, the crack pipe was secured by opening the forceps within the lumen of the glass stem. Finally, we questioned the ability of a slender, glass crack pipe to spontaneously clear the duodenal sweep. A previous case report described the management of a metal crack pipe that was ingested wholly.3 However, endoscopic removal was not attempted, and the patient was managed conservatively with serial abdominal radiographs that tracked the progression and eventual passage of the crack pipe. To our knowledge, this is the first report of an endoscopically removed crack pipe.
Conflicts of interest
The authors disclose no conflicts.