LETTER TO THE EDITOR:
A 28-year-old prisoner presented with a one-year history of dysphagia
and weight loss (BMI 18). Initially, he self-discharged from another
trust after CT neck suggested a plastic foreign body encapsulating
softer material lodged within a pharyngeal pouch at the level of T2-T3
(Figure 1). Referred as having “?Swallowed drugs”, he denied ingesting
any non-food items or recreational drugs although remained unable to
provide a cohesive history. Despite recently undergoing investigation
for mental health concerns, he reported no other significant past
medical history. Sinus bradycardia (33bpm) with a normal QTC incited
suspicion of systemic absorption of intra-corporeal illicit drugs. Given
the inconsistent history, bradycardia and imaging, the team maintained
high suspicion and pre-emptively sought guidance on the ethics of drug
testing and preservation of evidence. Unexpectedly, a plastic bottle cap
was removed during rigid panendoscopy, which contained digested food
substances. Pharyngoscopy revealed a significant oesophageal stricture
at 24cm with no cricopharyngeal bar suspicious of chronic inflammatory
stricture. 24-Hour ambulatory ECG recording confirmed only sinus
bradycardia. He was discharged back to prison once eating and drinking,
aiming for recurrent dilatation every two weeks until luminal diameter
reached >15mm.
Foreign body ingestion remains rare in adults but prevalence is greater
in the elderly, drug traffickers, prison inmates and patients with
psychiatric conditions[1]. Intentional ingestion of foreign bodies
is more common in incarcerated populations due to perceived secondary
gain, pica or psychiatric conditions[2]. Malingerers display
repetitive, intentional ingestion of multiple items and may be
associated with other self-harm behaviours[3]. Objects typically
include sharp metals, batteries or plastic-wrapped illegal drugs. The
prevalence of drug abuse within prison populations is high, with illicit
substances often concealed by body packing[4]. Rupture of packaging
with consequent leakage of contents may result in lethal intoxication.
Imaging is notoriously difficult to interpret as scybala, fruit stones
or grains may imitate packaged drugs.
Clinical judgement remains pivotal in formulating diagnoses and
optimising medical management. However, balancing rational associations
with unconscious bias is ethically challenging. A cautious balance must
be struck between implicit bias and clinical suspicion when considering
the management of oesophageal foreign bodies. Overall, we propose it is
clinically safer to manage such patients under the presumption that any
packaging contains illicit substances. However, no patient should have
their care compromised due to race, gender, age or background. As prison
populations continue to rise, further work needs to be done to tackle
implicit bias within a healthcare setting.
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