Gastrointestinal Unit, University Hospital of Birmingham NHS Trust, Queen Elizabeth and Selly Oak Hospitals, Raddlebarn Rd, Birmingham B15, UK
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Gastrointestinal Unit, University Hospital of Birmingham NHS Trust, Queen Elizabeth and Selly Oak Hospitals, Raddlebarn Rd, Birmingham B15, UK
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Gastrointestinal Unit, University Hospital of Birmingham NHS Trust, Queen Elizabeth and Selly Oak Hospitals, Raddlebarn Rd, Birmingham B15, UK
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Gastrointestinal Unit, University Hospital of Birmingham NHS Trust, Queen Elizabeth and Selly Oak Hospitals, Raddlebarn Rd, Birmingham B15, UK
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Gastrointestinal Unit, University Hospital of Birmingham NHS Trust, Queen Elizabeth and Selly Oak Hospitals, Raddlebarn Rd, Birmingham B15, UK
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Gastrointestinal Unit, University Hospital of Birmingham NHS Trust, Queen Elizabeth and Selly Oak Hospitals, Raddlebarn Rd, Birmingham B15, UK
Correspondence to:
Dr J R Butterworth
Royal Shrewsbury Hospital, Mytton Oak Rd, Shrewsbury SY3 8XQ, UK; moc.tenretnitb@htrowrettub.r.j
Keywords: foreign body, gastrointestinal tract, razor blades
Copyright © Copyright 2004 by Gut
See "Answer" on page 486.
Question
A 16 year old boy with a long history of self harm was admitted for the third time in four weeks with a history of ingestion of a number of shaving blades (fig 1 ▶). On previous occasions, endoscopic intervention with the use of an overtube under general anaesthesia had been successful in their safe retrieval. However, on the third occasion, a delay to endoscopy of 36 hours (due to a combination of late presentation and lack of access to the operating theatre) allowed the blades to progress beyond the pylorus into the small bowel, beyond the reach of a standard upper gastrointestinal endoscope (fig 2 ▶).
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Figure 1
X ray showing the razor blades in the small bowel, beyond the reach of a standard upper gastrointestinal endoscope.
Departments of Neurology (Drs Kunte and Harms), Gastroenterology (Dr Jürgensen), and Psychiatry and Psychotherapy (Drs Lang, Rentzsch, Kronenberg, and Hellweg), Charité-Universitätsmedizin Berlin, Berlin, Germany
Email: ed.etirahc@etnuk.negah
Potential conflicts of interest: None reported.
Funding/support: None reported.
Additional information: The authors have obtained signed consent from the patient with explicit permission to publish all of the patient’s data and materials. All authors have read the manuscript and approved submission.
Copyright © 2015, Physicians Postgraduate Press, Inc.
To the Editor: The means employed in self-injury vary widely among patients with borderline personality disorder and so may the magnitude of the damage inflicted. Deliberate foreign body ingestion is a frequent occurrence in patients with borderline personality disorder, but may also occur in patients with psychosis, malingering, and pica. The latter condition is defined as the persistent ingestion of nonnutritive materials such as chalk or clay at an age at which this behavior is developmentally inappropriate. The course of DFBI is frequently chronic. Treatment is difficult. Evidence-based therapeutic interventions are largely lacking.1 In borderline personality disorder, most self-injurious behaviors are a means of affect regulation and frequently lead to a swift release of tensions. In general, this release does not appear to be the reason behind DFBI.1 The main drivers behind DFBI in borderline personality disorder seem to be an inappropriate need for attention as well as a desire to test the limits of the therapeutic relationship. Management of DFBI in borderline personality disorder poses a great challenge because of potentially lethal complications and the need for rapid medical attention. Here, it is the special role of the consultant-liaison psychiatrist to bridge the gap between medical and physical health care and to support medical and surgical colleagues in grappling with countertransference issues commonly involved in treating such patients. In our experience, it is frequently during the early period after a major complication has occurred that the patient becomes more open to psychotherapeutic interventions. Ideally, general psychiatric management and stabilization will gradually enable the patient to benefit from a specific psychotherapeutic intervention such as dialectical behavior therapy.1,2