Endoscopic Retrieval of a Metallic Cross in a Patient With Acute Psychosis and Religious Delusions

CASE REPORT Deliberate foreign body ingestion (DFBI) is most frequently encountered in patients with underlying psychiatric disorders, the majority of whom have a history of prior DFBI.1 More than 80% of foreign body ingestions will pass spontaneously without intervention; however, DFBI more frequently requires endoscopic intervention at rates estimated between 63% and 76%, compared with incidental ingestion, which requires endoscopy roughly 20% of the time.2–5 We describe the case of a middle-aged man with a history of long-standing schizophrenia who was incidentally found to have an esophageal impaction secondary to ingestion of a metallic cross. A 53-year-old man with a history of chronic paranoid schizophrenia diagnosed in 2008 with frequent voluntary and involuntary hospitalizations, and difficulty with medication adherence was involved in a motor vehicle accident and presented to our institution's emergency department post-trauma. He had suffered multiple axial and appendicular skeletal fractures and was additionally found to be in acute psychosis. Trauma imaging incidentally revealed a metallic cross in the distal esophagus (Figure 1). Gastroenterology was consulted for retrieval of the foreign body, and emergent esophagogastroduodenoscopy was planned pending psychiatric evaluation due to concern regarding his decision-making capacity. He was promptly evaluated by psychiatry, who found that the patient had ongoing religious delusions. These included believing himself to be both a saint and a pope, which was the main reason for deliberately ingesting the metallic cross. In addition, he attributed his recent auto-pedestrian accident to the devil. He was unable to accurately describe neither the proposed procedure necessary nor the indication for procedure and therefore was deemed to lack decision-making capacity. Esophagogastroduodenoscopy was performed given the emergent need for foreign body retrieval and revealed a 4 cm metallic cross impacted in the lower esophagus just above the gastroesophageal junction (Figure 1). Retrieval was successful using an overtube and rat-tooth forceps with resultant localized esophagitis at the impaction site (Figure 1). He made an uneventful recovery following foreign body retrieval and was admitted for further inpatient psychiatric treatment.Figure 1.: (A) Computed tomography displaying esophageal foreign body impacted near the gastroesophageal junction (arrow). (B) 4 cm impacted metallic cross in the lower esophagus. (C) Foreign body retrieval using a rat-tooth forceps and overtube. (D) Localized esophagitis at impaction site (arrows).This case highlights the significance of early recognition of the potential complications associated with acute psychosis including DFBI. Over 100,000 cases of foreign body ingestion are reported annually in the United States, with more than 3 of 4 cases involving children.6–9 This report highlights the significance of characterizing the ingested foreign body to assess the urgency of endoscopic retrieval, thereby ensuring adherence to current guidelines. An impacted metallic cross in the esophagus, such as this, is characterized as a sharp-pointed object and is an indication for emergent retrieval.4 A multispecialty approach with prompt psychiatric evaluation allowed seamless transition to the necessary procedure and should be considered in all cases of foreign body ingestion related to acute psychosis, as corroborated by a systemic review of DFBI authored by Poynter et al.1 DISCLOSURES Author contributions: J. Malone drafted the manuscript; R. Abrol drafted the manuscript and obtained the images; J. Aguirre reviewed and approved the manuscript and is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.