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Paper text:
press - through packages ( ptps ) are commonly used to enclose drugs and are also increasingly seen in cases of foreign body in the digestive tract .
although commonly considered too small and soft to cause bowel damage , ptps tend to become caught and to pose a potential risk for perforation of the bowel because of their sharp edges .
removal should be attempted for a ptp in the esophagus or stomach , while computed tomography ( ct ) and early laparotomy should be considered if it passes through the pyloric ring and the patient develops symptoms .
efforts to prevent the swallowing of ptps should be an essential part of our everyday practice , particularly for elderly patients .
intestinal perforation resulting from accidental ingestion of a ptp has occasionally been reported . however , a search of the literature revealed no other cases of combined abdominal incisional hernia and perforative peritonitis due to accidental ptp ingestion .
a 90-year - old woman , who had been aware of repeated abdominal herniation over several months , was admitted to the emergency department of national hakodate hospital with severe abdominal pain .
she had a history of hysterectomy about 30 years previously and had developed swelling and redness in the resultant lower median abdominal scar .
serum biochemistry revealed the following : white cell count 3,700/mm ( normal < 9,500 ) ( segmented : 90% ) , c - reactive protein 14.79 mg / dl ( normal < 0.5 mg / dl ) , and creatine phosphokinase 230 iu / l ( normal < 119 iu / l ) .
abdominal ct showed an edematous intestinal tract image over the median abdominal wall ( fig .
1 ) . incarceration of abdominal incisional hernia was suspected and emergency surgery was performed .
the small intestine was herniated and incarcerated about 100 cm orally from the terminal ileum , and a 2-mm perforation was present in the incarcerated small intestine .
in addition , some white areas measuring 1 mm , which were considered to be the stimulation to intestinal wall by sharp corners of a ptp , were found in the intestinal wall . a ptp ( fig .
after dilation of the perforation to pass through , a ptp was removed through the perforation .
after surgery , when we retrospectively reviewed the preoperative abdominal ct , we detected a high - density shadow that appeared to represent the ptp ( fig .
after physical rehabilitation she was discharged in stable condition on the 40th day of hospitalization .
they consist of a lid coated with heat - sealed material on an aluminum leaf and a dome of vinylchloride .
the dome is pushed externally to expel a tablet or capsule ; therefore , it is called a press - through package . the mean size of a square ptp for a tablet is about 18  16 mm , and the mean size of a rectangular ptp for a capsule is about 30  16 mm . since small square pieces of ptps with sharp edges may break off , they tend to be caught and to pose a potential risk of bowel perforation when inadvertently swallowed .
in addition to lodging in the esophagus , mistakenly swallowed ptps have caused distal intestinal and colonic perforation or obstruction [ 2 , 3 ] .
although previous reports have noted that 80 - 90% of swallowed foreign bodies are spontaneously passed and that less than 1% cause perforation , ptps might be associated with a greater risk of perforation . as in the present case
, some patients may initially ignore accidental swallowing of a ptp and be subsequently admitted to hospital after deteriorating symptoms and signs [ 1 , 5 ] .
radiological tests play a very important role in revealing the presence , location and nature of an ingested foreign body , thus enabling the best therapeutic approach .
hence , in most of the reported cases , the correct diagnosis was not made until operation or endoscopic examination [ 1 , 3 , 6 , 7 , 8 ] .
however , hou et al . emphasized that air trapped in the ptp can make it visible on x - ray .
their cases were diagnosed after early correct interpretation of these specific radiographic findings . in a study by traub et al .
fulford and tooley reported that a previously unnoticed ptp was visible when the preoperative abdominal radiograph was reviewed . in the present case , however , the ptp was not visible on the preoperative abdominal radiograph , even when it was reviewed postoperatively .
early ct examination should therefore be considered in symptomatic patients to evaluate possible complications , as ct is more sensitive than plain radiography in detecting foreign body ingestion [ 5 , 10 ] .
it has been reported that patients with a history of abdominal surgery are at risk of obstruction from a foreign body that may lodge at a pre - existing stenosis and perforate the intestine [ 1 , 3 ] . however , no other cases of perforative peritonitis from an incarcerated incisional hernia associated with an inadvertently swallowed ptp have been reported .
the ptp reached the incarcerated intestine while it was prolapsed , and then irritated and perforated the wall .
physical pressure of the incisional hernia by the clothes may also have contributed to bowel perforation by the ptp .
accidental ingestion of foreign bodies is not uncommon , particularly in older patients and among those who are blind or mentally impaired .
having seniors cut up sheets of ptp by themselves when preparing their medications is a real hazard because of the possibility that they will not take the medication out of the package , and this practice should be avoided .
we therefore suggest that elderly people should be given their tablets after they have been unwrapped by a nurse or family member .
further , changes in packaging design might help prevent accidental ingestion or minimize adverse effects if ingestion does occur .
therefore abdominal ct should be performed routinely when a patient with acute abdominal pain is admitted .
in addition , it is essential to adequately explain to patients how to take their medications . improved design to avoid accidental ingestion and better training of patients in the use of ptps should decrease the incidence of this problem . in conclusion , although relatively rare , ptps are being seen increasingly in cases of foreign body in the digestive tract .
improved design to avoid accidental ingestion and better training of patients in the use of ptps could avoid complications of this condition , which is most likely to occur in elderly patients .
a 90-year - old woman was admitted to the emergency department of our hospital with abdominal pain and a fever of up to 39c . she had a history of hysterectomy about 30 years previously , and 
 redness and swelling were seen at the abdominal median scar . 
 serum biochemistry showed minor elevation of c - reactive protein and creatine phosphokinase . 
 abdominal computed tomography ( ct ) showed an edematous intestinal tract image over the median abdominal wall . 
 incarcerated incisional hernia and intestinal necrosis were suspected . 
 therefore , emergency surgery was performed . 
 on laparotomy , abundant purulent ascitic fluid was found . 
 the small intestine was incarcerated about 100 cm orally from the terminal ileum , and a 2-mm perforation was present in the incarcerated small intestine . 
 in addition , some white areas measuring 1 mm were found in the small intestinal wall . a press - through package ( ptp ) of a tablet 
 was confirmed in the intestinal tract near the perforated area . 
 we removed the ptp through the perforation and performed direct suture . 
 postoperatively , we retrospectively reviewed the ct image and found a high - density shadow which seemed to represent the ptp .