We present a case of a 29-year-old female with a psychiatric history as well as multiple foreign body ingestions who presented with a one-day history of abdominal pain. She ingested the foreign body three weeks prior to presentation. CT in the emergency department showed a foreign body identified as a ballpoint pen perforating the second portion of the duodenum and it was projecting at the subhepatic region with adjacent free fluid but no free intraperitoneal air. After multidisciplinary discussion with our surgical colleagues, patient went to the OR for attempt at endoscopic removal and endoscopic repair of perforation if needed. Our surgical colleagues were at standby. The patient received antibiotics prior to the procedure. After adequate sedation, the patient's esophagus was intubated and the endoscope was advanced under direct visualization to the third portion of the duodenum as you can see here. In the duodenum, a foreign body consistent with a ballpoint pen was identified. The sharp end of the pen perforated the second portion of the duodenum. The dull end of the pen ulcerated into the third portion of the duodenum with additional adjacent pressure ulcers located in close proximity, which can be seen here. Near the adjacent ulcer, the pen was slightly mobile. Therefore, we attempted to remove it using a snare initially, which you can see here. After multiple attempts at moving the pen to the distal small bowel without success, we changed our strategy and used a Roth tooth. You can see bleeding near the perforation at the second portion of the duodenum. However, the bleeding was minimal. You can see the Roth tooth here with gradual removal of the pen from the second portion of the duodenum while under direct visualization to minimize bleeding and contain the perforation if needed. We were able to dislodge the sharp end of the pen and move it distal to the small bowel and observe the area of perforation. This revealed a contained perforation with minimal oozing. We were able to remove the pen gently from the small bowel to the stomach through the esophagus and out of the patient. We went in again to take a look at our site and to observe any damage. As you can see, this is the second portion of the duodenum. Here you can see where the contained perforation is, with an adherent clot and no active oozing. After removal, the patient had an upper GI series performed, which did not show any leakage. The patient did well post-procedure and was discharged without any further complications. Foreign body ingestion is a commonly encountered condition by gastroenterologists. Most of the time, foreign bodies in the esophagus and stomach can be removed safely by endoscopy. On the other hand, small bowel foreign bodies are frequently removed surgically if retained. Typically, foreign bodies tend to pass the entire small bowel if they are small enough to traverse through the pylorus. However, if they are retained, the risk of perforation is increased. Current reported estimated incidences of small bowel perforation due to foreign bodies is less than 4%. Laparoscopy with primary suture of the intestine is the mainstay of diagnosis and treatment for these types of cases. In this video, we demonstrated that endoscopic removal of foreign body perforating the duodenum can be considered as an alternative to surgery as long as the patient remains stable without an acute abdomen. We also demonstrated that a perforated site caused by the foreign body can close spontaneously upon removal of the foreign body as long as no significant fibrosis has developed. While endoscopic closure of small bowel perforation is possible with the appropriate skills and devices, the need for surgical backup should always be available if endoscopic attempts fail.

case study

endoscopic removal

duodenum perforation

foreign body ingestion

surgical backup