Chronic swallowers: don’t read this while eating

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“This will be her 63rd EGD,” the GI fellow sighed. “Oh well. She hasn’t perforated yet.”

I encountered this patient in medical school, a 35-year old woman who had been living at the state psychiatric hospital for years already. This time, she had “absconded” during a group trip to Walmart, snuck over to CVS, and swallowed a whole bottle of aspirin because it was the cheapest pill that was available. In the past she had swallowed things ranging from pens to steak knives, and had to have one person standing on either side of her to prevent her from swallowing because she was so fast.

This time, when she swallowed the aspirin, she threw up immediately afterwards and developed aspirin toxicity. She kept on repeating that she wanted to be better, and she didn’t know she was going to be that sick. She had what we call a “terminal personality.”

Pathological swallowing did not really enter the medical literature until the early 1990s, according to this historical case report . Most patients had command hallucinations to swallow, although these days, there is a greater correlation with prisoners and psychiatric patients who swallow to try to buy time outside their institution. A more recent case series shows that the swallowed objects can usually be retrieved by endoscopy, with low risk for perforation or death. However, it costs millions of dollars, and is very frustrating for the team taking care of a patient who keeps on presenting for the same reason again, and again, and again.

There are some interesting forensic and legal questions raised by the idea of doctors treating patients who have ingested foreign bodies, especially if the patient is the subject of a criminal investigation. United States v. Black was a case that questioned whether a physician was acting as a police agent by conducting a search of a defendant’s body cavity (although in this particular case, it seems very clear that the doctors were acting on behalf of the police).

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