ingested bread clip as an unexpected diagnostic tool...mckinley j, brady p7 2008 1 known ingestion...

90 NZMJ 23 March 2018, Vol 131 No 1472ISSN 1175-8716 © NZMAwww.nzma.org.nz/journal

Ingested bread clip as an unexpected diagnostic tool

Sharon Jay, Michael Russell, Yee Lau, Joel Dunn, Ross Roberts

This 76-year-old woman initially pre-sented to a peripheral hospital three months prior with generalised ab-

dominal pain associated with nausea. There was no vomiting, and her bowels functioned normally. An incidentally raised CA-125 of 209kIU/L was noted by her general prac-titioner two weeks prior to presentation.

Radiological investigation with ultrasound showed a linear echogenic structure asso-ciated with a loop of small bowel in the left adnexa and was thought to represent a tubal ligation clip (Figure 1). Computed tomog-raphy (CT) scan was reported as having no acute abnormalities. The pain resolved spontaneously and she was discharged.

ABSTRACTWe describe a case where a bread clip has in fact became lodged adjacent to a portion of small bowel a� ected by a deposit of previously undiagnosed metastatic serous carcinoma of likely ovarian origin.

Figure 1: Ultrasound scan showing linear echogenic structure (white arrow) associated with a loop of small bowel in the left adnexa, initially thought to represent a tubal ligation clip.

CLINICAL CORRESPONDENCE


The patient then re-presented, three months after initial presentation, with a 10-day history of abdominal pain, which again, resolved spontaneously. Repeat CT in the community showed a foreign body consistent with a bread clip in the small bowel in the left side of the abdomen (Figure 2). There were no acute associated fi ndings. In retrospect this foreign body was evident on the previous scan. The patient was then transferred to our institution for further management. The patient was unaware of ingesting the bread clip.

On examination her abdomen was soft, with tenderness in the left lower quadrant. There was no peritonism and bowel sounds were normal. Laboratory investigations showed a normal white cell count and a C-reactive protein of 10mg/L. Repeat CT scanning showed infl ammatory changes around the likely bread clip with no evidence of overt obstruction (Figures 3–5). Given the infl ammatory changes on CT scanning, the patient was brought forward for laparotomy and small bowel resection.

Operative fi ndings were of a normal appearance of the bowel, however, in the mid small bowel there was an area of infl am-mation and fi brosis. The bread clip was felt within the lumen. The area in question was resected, and the bowel anastomosed. The ovaries were not specifi cally examined but no gross abnormality was seen.

The patient had a post-operative ileus, which resolved, and she was discharged on the seventh post-operative day.

The operative histology revealed bread tag impacted on the mesenteric side of the bowel mucosa with fi bro-infl ammatory change (Figure 6). Unexpectedly, the area adjacent to the impacted bread clip showed malignant tumour in the serosal and subserosal tissue. The tumour included high-grade malignant epithelial cells with characteristics favouring metastatic high-grade serous carcinoma of gynaecological origin. It was suggested that this metastatic tumour resulted in a stricture causing the bread clip to become impacted at this part of the small bowel.

Figure 2: Coronal CT showing bread clip (white arrow) within the lumen of small bowel.



Figure 4: Saggital CT image showing bread clip (white arrow) within lumen of small bowel.

Figure 3: Axial CT demonstrating the bread clip (white arrow) within lumen of small bowel.



Figure 5: Reconstructed coronal CT image showing bread clip (white arrow) within lumen of small bowel.

Figure 6: Photograph of the resected small bowel showing small bowel mucosa invaginated within plastic bread clip.



DiscussionThe origin of the bread clip can be traced

back to the 1950s, when it is reported that Floyd Paxton fi rst used a piece of plastic to carve the fi rst bread clip to close plastic bags containing apples.1,2 Despite their extensive use, alternatives have been suggested and used, as many publications have called for discontinuation due to complications after accidental ingestion.2–5 Many bread companies in the UK are using plastic tape as a safer alternative.6

More than 20 ingested bread clip case reports or small case series have been published. They describe and document various aspects of the complications asso-ciated with this phenomenon such as

intestinal ulceration, obstruction, perfo-ration and even death. These complications are summarised below (Table 1). Bread clips have two characteristic inward facing curved hooks, which when ingested can cause bowel mucosa to become invagi-nated in the clip mechanism causing the aforementioned complications. While endoscopic removal of a foreign body is seen as fi rst line treatment there are only a few documented such cases with bread clip ingestion.7,8 Given the initial indolence and the unknown ingestion of the clip, complica-tions are usually too distal to be retrieved in this way. Subsequently, surgery with bowel resection is the most common management of this condition.

Table 1: Review of literature showing recorded case reports and small case series of ingested bread clip.

Authors Year published Number of cases Complication

Medline A, Shin D9 1975 1 Intestinal perforation

Rivron RP, Jones DRB10 1983 1 Intestinal perforation

Jamieson MH, et al11 1983 1 Intestinal perforation

Bundred NJ, et al12 1984 2 Intestinal ulceration and perforation

Sutton G13 1984 3 Ileocolic intussusception, abscess and two fatalities

McKaigney J, et al14 1985 1 Intestinal perforation

Guindi M, et al15 1987 3 Incidental findings at post-mortem

Ellul JPM, Hodgskinson PD16 1989 1 Intestinal ulceration and perforation

Norrie M, et al17 1997 1 Intestinal ulceration

Newell K, et al3 2000 5 Intestinal perforation or incidental

Cook D18 2001 1 Incidental at post mortem

Beer W6 2002 2 Fatality due to perforation

Tang A, et al4 2005 1 Perforation and abscess

Morrissey S, et al8 2008 1 Ulceration and gastrointestinal bleed

McKinley J, Brady P7 2008 1 Known ingestion and endoscopic retrieval

Allsopp T, Fraser-Kirk G5 2009 1 Intestinal ulceration and perforation

Lehmer L, et al19 2011 1 Incidental

Koh M, Wright RG20 2013 1 Intestinal ulceration

Nambu R, et al21 2016 1 Intestinal perforation

Greenup A, et al22 2016 1 Local mucosal trauma

Bhardwaj N, et al23 2016 1 Intestinal obstruction

Bakia J, et al24 2017 1 Intestinal perforation



1. Kwik Lok Corporation [Internet]. Available from: http://www.kwiklok.com

2. Karro R, Goussard P, Loock J, Gie R. The simple bread tag - a menace to society? S Afr Med J. 2015 Apr 7; 105(5):342–4. doi: 10.7196/samj.8996.

3. Newell KJ, Taylor B, Walton JC, Tweedie EJ. Plastic bread-bag clips in the gastrointestinal tract: report of 5 cases and review of the liter-ature. CMAJ. 2000 Feb 22; 162(4):527–9.

4. Tang AP, Kong AB, Walsh D, Verma R. Small bowel

perforation due to a plastic bread bag clip: the case for clip redesign. ANZ J Surg. 2005 May; 75(5):360–2.

5. Allsopp T. An unusual cause of small bowel perforation. Has anything changed? Internet J Surg. 2010; 23(2):1–5.

6. Beer TW. Fatalities from bread tag ingestion. Med J Aust. 2002 May 20; 176(10):506.

7. McKinley JM, Brady PG. Bread Bag Clip: Kitchen Aid or Gastrointestinal Barricade? Gastroenterol Hepatol (N Y). 2008; 4(7).

8. Morrissey SK, Thakkar SJ, Weaver ML, Farah K. Bread bag clip ingestion: a rare cause of upper gastrointestinal bleeding. Gastroenterol Hepatol (N Y). 2008 Jul; 4(7):499–500.

9. Medline A, Shin D. Letter: Unusual cause of small-bowel obstruction. Can Med Assoc J. 1975 Oct 4; 113(7):608.

10. Rivron RP, Jones DR. A hazard of modern life... Lancet. 1983 Aug 6; 2(8345):334.

11. Jamison MH, Davis RW, Maclennan I. A plastic bread-bag clip--cause of

REFERENCES:

Competing interests:Nil.

Acknowledgements:Thanks to Dr Matthew Drake for the photograph of the histological specimen used in Figure 6.

Author information:Sharon M Jay, Department of General Surgery, Christchurch Hospital, Christchurch;

Michael J Russell, Department of General Surgery, Christchurch Hospital, Christchurch; Yee C Lau, Department of General Surgery, Christchurch Hospital, Christchurch;

Joel W Dunn, Department of Radiology, Christchurch Hospital, Christchurch; Ross Roberts, Department of General Surgery, Christchurch Hospital, Christchurch.

Corresponding author: Dr Sharon M Jay, Department of General Surgery, Christchurch Hospital, Riccarton Road,

[email protected]

URL:http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2018/vol-131-no-1472-

23-march-2018/7532

In this case, we describe a case of bread clip ingestion, which initially seemed to be an uncomplicated case. However, after failure to pass the ingested clip, surgical excision of the affected small bowel and subsequent histological analysis of the specimen showed the bread clip had in fact became lodged adjacent to a portion of small bowel affected by a deposit of previously undiagnosed metastatic serous carcinoma of likely ovarian origin.

Literature on this topic identifi es the danger associated with ingestion of bread clips. Our case supports the assertion that

bread clips present a potential public health issue. Bread clips are readily identifi able on CT due to plastic’s high attenuation value, but this is the fi rst reported case where a bread clip is demonstrated on an ultrasound, albeit with the benefi t of retrospect.

The combination of the ingested bread clip and the subsequently identifi ed pathological fi ndings in this case is certainly unique. This reinforces the importance of sending all operative specimens for histological analysis, as rare and unexpected fi ndings can have signifi cant implications.



intermittent intestinal obstruction. Br J Clin Pract. 1983 Nov–Dec; 37(11–12):402–3.

12. Bundred NJ, Blackie RA, Kingsnorth AN, Eremin O. Hidden dangers of sliced bread. Br Med J (Clin Res Ed). 1984 Jun 9; 288(6432):1723–4.

13. Sutton G. Hidden dangers of sliced bread. Br Med J (Clin Res Ed). 1984 Jun 30; 288(6435):1995.

14. McKaigney J, Cole M, Simon JB. Picking up the tab: obstruction of the gastrointestinal tract by plastic bread bag clips. Gastrointest Endosc. 1985 Apr; 31(2):112–3.

15. Guindi MM, Troster MM, Walley VM. Three cases of an unusual foreign body in small bowel. Gastrointest Radiol. 1987; 12(3):240–2.

16. Ellul JP, Hodgkinson PD. Problems with a plastic bread-bag clip. Arch Emerg Med. 1989 Jun; 6(2):156–7.

17. Norrie MW, Chapman G, Connor SJ. A case of upper gastrointestinal bleeding secondary to a bread bag clip. Aust N Z J Med. 1997 Feb; 27(1):75.

18. Cook DS. Dietary dangers: ingestion of a bread bag clip. J Clin Pathol. 2001 Jan; 54(1):79.

19. Lehmer LM, Ragsdale BD, Daniel J, Hayashi E, Kvalstad R. Plastic bag clip discovered in partial colectomy accom-panying proposal for phylogenic plastic bag clip classifi cation. BMJ Case Rep. 2011 Sep 4; 2011. pii: bcr0220113869. doi: 10.1136/bcr.02.2011.3869.

20. Koh M, Wright RG. A case of a wayward bread bag clip: and unusual cause of intestinal ulcercation. Pathology. 2013; 45(S1):73.

21. Nambu R, Hagiwara S, Kagimoto S. Long-term Retention of Plastic Bread Bag Clip That Grips

and Perforates the Colonic Mucosa. Gastro-enterology. 2016 Sep; 151(3):396–7. doi: 10.1053/j.gastro.2016.04.046. Epub 2016 Jul 30.

22. Greenup AJ, Wright D, Koorey D. EDUCATION AND IMAGING. Gastrointestinal: Bread bag clip ingestion: Cause for concern. J Gastro-enterol Hepatol. 2016 Feb;31(2):283. doi: 10.1111/jgh.13192.

23. Bhardwaj N, Kanhere HA, Maddern GJ. Small bowel obstruction caused by a bread clip: a time and time again problem. ANZ J Surg. 2016 Jan-Feb; 86(1–2):94–5. doi: 10.1111/ans.12598. Epub 2014 Apr 9.

24. Bakia JM, Ovaere S, Dijkman FP, Schipper EE. The dangers of the bread clip – CT imaging and management: a case report. Acta Chir Belg. 2017 Aug; 117(4):264–266. doi:10.1080/00015458.2016 .1258827. Epub 2016 Nov 24.


ingested bread clip as an unexpected diagnostic tool...mckinley j, brady p7 2008 1 known ingestion...

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