Discussion
The great majority of smaller foreign bodies that are ingested will pass through the gastrointestinal tract without giving rise to problems. Intestinal injuries can occur when the foreign body is sharp or indigestible, such as chicken bones, fish bones, toothpicks, nails or small, angular cake decorations (1) – (3) which can cause bleeding, ulceration, formation of fistulas or perforation. Gastrointestinal complications due to tablet packaging are uncommon, but have been described previously (4). Intestinal perforation often occurs in the terminal ileum, a few centimetres above the ileocaecal valve. Perforations can also occur in other parts of the small intestine – the caecum, sigmoid colon or duodenum (5) – (8). Children, as well as elderly people with reduced vision and/or other serious illnesses, are more susceptible to this risk.
Tablets are often sold in boxes containing tablets in plastic cavities sealed within a card covered with aluminium foil (blister packs). The tablets are intended to be pushed out through the aluminium foil before ingestion. Sometimes there are perforations between the individual blisters to make it easier to press a dose or a tablet out while still protecting it. Many cards do not have these perforations and may need to be cut away from the card if single-dose units are desired. Our patient had swallowed a single tablet in its blister pack. The blister pack was broken or cut loose from the card and consisted of a hard, square-shaped object with very sharp corners which she was handed and swallowed together with her other regular drugs. The fact that she had just undergone another illness which had left her weak, and that she had poor vision and reduced sensitivity in her oral cavity due to dental prostheses, were among the reasons she did not notice that the tablet was still in its blister pack and therefore swallowed it whole.
Clinically it is impossible to distinguish perforations of the small intestine from perforations in other parts of the gastrointestinal tract. An abdominal CT scan with contrast medium is the best form of examination for rapid determination of the cause of acute conditions of the abdomen, in this case a foreign body, and for localisation of the intestinal perforation (8). Laparotomy with small bowel resection is necessary. Laparascopic intervention may be an alternative method.
In future years the number of elderly, ill patients taking tablets will steadily increase. One way of preventing this condition is to use other forms of single-tablet packaging than blister packs.