Accidental ingestion of hijab pin in an infant and successful removal by upper gastrointestinal endoscopy: A case report

INTRODUCTION

Foreign body (FB) ingestion is a significant concern in pediatric patients due to their natural curiosity and tendency to explore objects orally. Cultural factors greatly influence the type of sharps ingested like esophageal fish bones which are mostly encountered in Asian and Mediterranean descent, where fish is introduced into the diet at a young age whereas pin ingestions are higher in ethnic groups that use pins for scarves and hijabs due to religious or cultural beliefs or to fasten clothing and diapers.^[1] Most common symptoms are drooling, pain, and dysphagia which usually appear when FB is lodged in esophagus and pain when the sharp object is in stomach and beyond.^[1] A plain radiograph is the first line of investigation^[1,2] and timely endoscopic intervention especially in cases of symptomatic sharps in esophagus and stomach is mainstay of treatment.^[1-3]

We present an 8 months 23 days old girl who accidentally ingested a hijab pin which was removed successfully by endoscopic retrieval with a 9.2 mm scope, 2 days after ingestion.

CASE REPORT

An 8-month 23 days old female child, second by birth order, born out of non-consanguineous marriage was bought to the emergency department after the ingestion of hijab pin in January 2023. The child was playing with a packet containing many such pins with colorful rounded tip on one end and sharp tip on the other end. While playing the child inserted one of the pins into her mouth. Her mother noticed this and attempted to remove the FB, but it inadvertently went further into the child’s mouth. Subsequently, the child started coughing vigorously, expelling saliva, but later appeared to be fine. There was no reported history of breathlessness, vomiting, hematemesis, abdominal distension, or difficulty in swallowing. The child had no previous episodes of FB ingestion, and her medical history was unremarkable. The child was primarily on breastfeeds and had normal growth and development.

On examination, the child appeared in good condition with stable vital signs. Pallor and frontal bossing were noted on physical examination. The child’s weight was 5.6 kg (<3^rd centile as per World Health Organization [WHO] growth charts) and length was 66 cm (between ^3rd and 5^th centile as per WHO growth charts). Systemic examination revealed no abnormal findings. Serial erect abdomen X-rays showed a non-progressive vertical liner shadow. CT scan was suggestive of linear radiodense FB in proximal duodenum with its upper end eroding through the duodenal wall and abutting inferior surface of liver along segment IV B. She was taken for upper gastrointestinal (UGI) endoscopy using Olympus GIF Type Q150, 9.2 mm UGI scope, and EVIS EXERAIII CLV190 processor. To prevent respiratory compromise or aspiration during retrieval of pin, the baby was intubated with a size-4 noncuffed endotracheal tube. On UGI endoscopy, 4 cm long Hijab pin was seen impacted in 2^nd part of duodenum (D2) [Figures 1 and 2]. Pin was disimpacted from duodenal mucosa using rat tooth forceps and retrieved using a polypectomy snare keeping the sharp end of the pin pointed toward the scope. Post-retrieval a check UGI endoscopy was done till 3^rd part of duodenum. No active bleeding or injury noted through-out the visualized UGI tract. Post-procedure recovery was uneventful and the child was discharged successfully.

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Figure 1:

Hijab pin was seen impacted in 2^nd part of duodenum (D2) on upper gastrointestinal endoscopy.

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Figure 2:

4 cm Hijab pin exhibit.

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DISCUSSION

FB ingestion is one of a common cause of pediatric patients visit to emergency department. Children tend to swallow household items such as coins, pins, nails, magnets, toys, fishbone, jewelry, and button batteries.^[4] Cases of hijab pin ingestion are seen more in young Muslim hijabis, with most of the reported cases occurs in the 11–20 years age group where they carelessly hold the pin between their lips or teeth and accidentally swallowed while talking or coughing.^[2] Although the ingested pin in our patient stayed in duodenum uneventfully yet, impaction of a sharp object in the tract has been known to cause local inflammation leading to bleeding and obstruction.^[2] Multiple complications have been reported such as gut perforation, extra-luminal migration, abscess formation, penetration of liver, heart, and lung,^[1] rupture of common carotid and death.^[5] The most common site for intestinal perforation is ileocecal region, but perforations have also been reported in the esophagus, pylorus, duodenum, and colon.^[6,7]

For suspected FB ingestion, radiographs are the 1^st modality of investigation with 100% positive predictive value for metallic objects.^[1,2] CT should be considered when complications such as abscess or obstruction are suspected.^[2] In our case, position of the pin remained same and in vertical position in serial radiographs, hence raising a concern of impaction and warranting the CT.

Time to perform endoscopy depends on clinical status of the patient, nil per oral (NPO) status, type of object ingested, and location in the gastrointestinal tract. In general, the time to perform endoscopy in symptomatic esophageal, gastric, and small bowel is emergent retrieval (<2 h from presentation, irrespective of NPO status) and, in asymptomatic cases, it is urgent retrieval (<24 h from presentation, following NPO).^[1] The technique and instruments used for removal of sharp objects is a very important aspect as while retrieving sharps, there are chances of mucosal injury or tear. Magill forceps with direct laryngoscopy are useful for removing sharp FB lodged in the oropharynx or cricopharyngeus.^[8] Retrieval forceps, retrieval net, and polypectomy snare can be used for grasping sharp objects.^[1] About 96% success rate has been reported for retrieval of sharp FB from the UGI tract using rat tooth forceps.^[9] Polypectomy snare is a good choice for longer sharp objects^[10] like we did in our case.

The fundamental principles for endoscopic retrieval of foreign bodies are airway protection, to sustain control of the object during extraction, and to avoid causing additional damage. Endotracheal intubation may be necessary sometime, especially in younger children like we did for our patient and those at higher risk for aspiration. The use of an esophageal overtube and a latex protector hood may facilitate the safer extraction of pointed or sharp objects.^[1-4] In our case, we did not use overtube or hood due to limited access as the baby was only 5.6 kgs in weight.

CONCLUSION

This case highlights the importance of early identification, appropriate imaging, and timely endoscopic intervention in managing sharp foreign body ingestion in infants. A multidisciplinary, cautious approach—emphasizing airway protection and careful retrieval technique—can prevent serious complications and ensure successful outcomes, even in challenging cases like duodenal hijab pin impaction.