Bowel obstruction caused by an intrauterine device into the abdomen cavity: A case report at 103 Military Hospital

Using an intrauterine contraceptive device is a highly effective and reliable method of contraceptive. It has been widely applied in the world due to its high efficiency, low risks and low cost. However, it may cause some important complications, one of these complications is migration of the intrauterine contraceptive device to adjacent organs into the abdomen cavity. We reported one case of female patients, 72 years old, who had an intrauterine contraceptive device for more than 30 years. 3-day onset of disease with bowel obstruction syndrome, abdominal pain, nausea and vomiting, no farting.

Journal of military pharmaco-medicine no7-2019 BOWEL OBSTRUCTION CAUSED BY AN INTRAUTERINE DEVICE INTO THE ABDOMEN CAVITY: A CASE REPORT AT 103 MILITARY HOSPITAL Ho Chi Thanh1; Dang Viet Dung1; Nguyen Van Thanh1 SUMMARY Using an intrauterine contraceptive device is a highly effective and reliable method of contraceptive It has been widely applied in the world due to its high efficiency, low risks and low cost However, it may cause some important complications, one of these complications is migration of the intrauterine contraceptive device to adjacent organs into the abdomen cavity We reported one case of female patients, 72 years old, who had an intrauterine contraceptive device for more than 30 years 3-day onset of disease with bowel obstruction syndrome, abdominal pain, nausea and vomiting, no farting Abdominal X-rays and CT-scans showed bowel obstruction, intrauterine contraceptive device located in the abdomen cavity The patient was given emergency surgery, revealed a segment of ileum entered into the loop of intrauterine contraceptive device, which caused the small bowel obstruction and necrosis of the ileum A segmental bowel resection was performed by stapler and side-to-side anastomosis The patient th th recovered well, fed on the day and was discharged on the day after surgery * Keywords: Bowel obstruction; Intrauterine device INTRODUCTION An intrauterine device (IUD) also known as intrauterine contraceptive device (IUCD) or coil, have been widely used all over the world and Vietnam because of convenience, cheapness and efficiency However, it also has some potential complications such as abdominal pain, bleeding and uterine perforation [1] IUDs move into the abdomen, according to many reports, is less than 0.1%, but this is a dangerous complication because it could damage to the abdominal organs such as intestinal perforation, intestinal obstruction and intestinal necrosis all of them could cause peritonitis [2, 3] We made a report on a case of a 72 years old woman, who had had an IUD fitted for over 30 years The complication on her is that IUD entered to her abdomen causing necrosis of the ileum THE CASE REPORT * Disease history: - A female patient, 72 year old, sickly body, 152 cm tall, 35 kg The disease started days ago Her symptoms were intermittent abdominal pain, nausea and vomiting food, squash of bowel movements, abdominal distention gradually, and then there were some symptoms of peritonitis syndrome on her 103 Military Hospital Corresponding author: Ho Chi Thanh (hochithanhbv103@gmail.com) Date received: 13/07/2019 Date accepted: 23/08/2019 151 Journal of military pharmaco-medicine no7-2019 - The patient had been treated according to mechanical obstructive obstruction regimen at a district hospital for days before moving Treatment measures were fasting, passing stomach sonde through, infusion of electrolytes, antibiotics and vitamins, but she had not feel better, so they transferred her to the 103 Military Hospital to treat - Abdominal X-ray examination: The image of intestinal obstruction (fig.1) - Computed tomography: The image of an IUD in her small frame of the abdomen (fig.2) Table 1: Results of blood tests before and after the surgery Type of test * Medical history: Before operation After operation 72 hours 9.2 mmol/L 5.8 mmol/L 125.8 µmol/L 61.2 µmol/L - No times being to have an abdominal surgery in the past Ure - Having an IUD fitted about 30 years ago Protein 65.4 g/L 56.4 g/L Albumin 35.5 g/L 27.8 g/L 120 mmol/l 134 mmol/L 2.8 mmol/L 3.6 mmol/L 92 mmol/L 96 mmol/L 1.96 mmol/L 2.21 mmol/L 4.1 Tera/L 3.5 Tera/L Hgb (Hb) 113 g/L 98.0 g/L * Medical examination: Creatinine Na + + - On the first day, the symptoms on her body were the intestinal obstruction, abdominal pain, vomiting, squash, abdominal distention, the sign of snake crawling There was the line of separating the air from the solution in her bowels on her abdominal X-ray K Hct 0,41 L/L 0.36 L/L - On the third day, there were some symptoms of peritonitis syndrome on her, such as: dirty tongue, bad breath, high fever of 38.5oC, nausea and vomiting, abdominal distention, pain throughout the abdomen, quash of bowel, peritoneal touch, the Blumberg sign WBC 18,5 G/L 12,7 G/L 88% 75% 260 G/L 223 G/lL Cl - Ca + RBC Neutrophil PLT - The test of her blood: Elevated white blood cell counts, especially young white blood cells * Diagnostic tests: - Blood test showed that the patient had the water and electrolyte disorder sign, acute renal failure, concentrated blood and elevated white blood cell counts (table 1) 152 Figure 1: Abdominal X-ray Journal of military pharmaco-medicine no7-2019 * Diagnosis after surgery: Peritonitis and ileum necrosis caused by an IUD into the abdominal cavity * Surgical method: Cutting the ileum necrosis containing the uterine device and the ileum to ileum side to side anastomosis - The patient was intubated anesthesia Figure 2: Abdominal computed tomography scan Figure 3: The IUD in her abdomen - After slitting the patient’s skin following the white and middle belly skin from above to below the navel to reach the patient’s abdominal cavity, we saw some black-brown fluid We found a segment of stretched and black-purple ileum There was an IUD that impaled the segment of ileum that was about 80 cm from the ileum-caecum angle (fig 3, 4) - Removal of the necrotic segment containing the IUD, suturing the ileum to ileum side by side, checking the circulation of the connecting ileum mouth, recovering the mesenteric cavity, rising the abdominal cavity, rearranging the intestine, placing a drain from the Douglas to outside, closing the abdomen of two layers * Surgical results: After surgery, the patient was awake, drawn the endotracheal tube out after hours and treated at the intensive care unit Figure 4: IUD and a piece of necrotic intestines * Diagnosis before surgery: Peritonitis caused by an IUD into the abdominal cavity On the second day after surgery, the patient was taken back the department of abdomen She had to fast because of being reared through her venae instead Tests showed the improving of the water and electrolyte disorder sign, urine volume was 1.8 litres per 24 hours The fluid from the drain was transparent and 50 millilitres per 24 hours The patient broke wind for 153 Journal of military pharmaco-medicine no7-2019 the first time after the surgery 72 hours The indicators of electrolyte biochemical tests were improved (table1) We let her having snacks from the 4th day after the surgery and withdrew the Douglas drain on the 5th day The patient was discharged on the 7th day DISCUSSION Diagnosis Diagnosing intestinal obstruction caused by ectopic IUD into the abdominal cavity is not difficult The clinical signs of the patient are the typical intestinal obstruction symptoms with abdominal pain, nausea, vomiting and abdominal distention and peritonitis symptoms when the bowel is gangrenous We can see the signs of bowel obstruction and the foreign body in the abdominal cavity in the abdominal X-ray film The signs on abdominal CT-scanner or MRI film were clearer than X-ray, they even can determine the place of the foreign object exactly [4] Abdominal CT-scanner can show a ectopic IUD when symptoms are not present, so with female patients who had an IUD before and come for an examination and if we could not find an IUD in their uterus, then we had to scan their abdominal cavity to diagnose Aydogdu et al reported a 68-year-old patient with an IUD for over 30 years She was had X-ray and CT-scanner accidentally and they found an ectopic IUD in her abdominal cavity After that, she underwent a laparoscopic surgery to remove the IUD [5] Park.J et al also reported a 42-year-old female patient with an IUD for over years [2] She felt 154 only ambiguous abdominal pain They could not find the IUD in her uterine cavity, but found it in her colon through X-ray film and colonoscopy and then they decided to take it off according to the colonoscopy when there was no complication Surgery IUD in the abdominal cavity caused intestinal necrosis is an unsafe complication that need being indicated emergent surgery to remove the segment of intestinal necrosis and to recover the circulation of bowels If the complication is on the small intestine, the abdominal cavity is clean and habitus of patients is good, so we can connect instantly With this patient, we connected the ileum vertically, because the diameter of the front ileum segment was larger than the rearward If the intestinal segment necrosis was in the colon, we had to take a segment of colon out to make an artificial anus, clean the abdominal cavity and put drains after cutting the segment of colon necrosis We can put one or more drains, it depends on the abdominal cavity condition This patient had a clean abdominal cavity so we put only one Douglas drain and withdrew it on the 5th day after surgery Brar R et al reported a 64-year-old female patient with an IUD over 31 years, who was diagnosed intestinal necrosis caused an ectopic IUD in her abdominal cavity Yanh H.W et al also reported a 77-year-old female patient with an IUD over 30 years, who was diagnosed intestinal necrosis caused an ectopic IUD in her abdominal cavity, too Both of them underwent a surgery to remove the ectopic IUDs and Journal of military pharmaco-medicine no7-2019 cut the intestinal necrosis [6, 7] From that point, we can see that ectopic IUDs in abdominal cavity usually cause the bowel perforation and intestinal necrosis We can use laparoscopic surgery to remove the ectopic IUDs with asymptomatic intra-abdominal IUD cases Shah B.C et al reported a 35-year-old patient who went to take the examination for gallbladder stones and was discovered an intraabdominal IUD The patient underwent a laparoscopic surgery to check and remove IUD while it was entering the sigmoid colon wall [8] Post-operative care During the post-operative period of cutting a segment of the intestinal necrosis, patients need to fast because of being reared through her venae instead and undergo the medical treatment with antibiotics, electrolyte rehydration and avoiding acute renal failure When the patients are able to breathe by themselves, we can let them exercises soon in their bed, change incision bandages and withdraw their drains soon to avoid the bowel adhesions after surgery When the patients broke wind for the first time, we should let them some snacks In this case, we gave the first meal on the 4th day after surgery, withdrew the drain on the 5th day, cut the medical threads and discharged her on the 7th day The patient was rehabilitated very well CONCLUSION Intrauterine device that is placed in the uterus for women of reproductive age should be checked regularly at the specialized medical facility When they are not in the uterus, the patients should be exam by X-rays and CT-scanner as soon as possible to determine the losing of IUD place We should appoint to laparoscopic abdominal surgery soon to find and remove the IUD to avoid complications of intestinal obstruction, perforation and intestinal necrosis REFERENCES Mosher W.D, Jones J Use of contraception in the United States: 1982 - 2008 Vital Health Stat 2010, 23 (29), pp.1-44 Park J.M, Lee C.S, Kim M.S et al Penetration of the descending colon by a migrating intrauterine contraceptive device J Korean Soc Coloproctol 2010, 26 (6), pp.433-436 Takahashi H, Puttler K.H, Hong C, Ayzengart A Sigmoid colon penetration by an intrauterine device: A case report and literature review Military Medicine 2014, 179, pp.127-129 Boortz H, Margolis D, Ragavendra N et al Migration of intrauterine devices: Radiologic findings and implications for patient care Radiographics 2012, 32 (2), pp.335-353 Aydogdu O, Pulat H Asymptomatic farmigration of an intrauterine device into the abdominal cavity: A rare entity CUAJ 2012, (3), pp.134-136 Brar R, Doddi S, Ramasamy A, Sinha P A forgotten migrated intrauterine contraceptive device is not always innocent: A case report Case Reports in Medicine 2010, pp.1-3 Yang H.W, Zhou Z.G Small bowel obstruction caused by migrated intrauterine contraceptive device: A case report Biomed Res 2017, 28 (22), pp.1-3 Shah B.C, Degloorkar S Intrauterine contraceptive device in peritoneal cavity invading sigmoid colon Journal of Case Reports 2014, (1), pp.193-195 155 ... findings and implications for patient care Radiographics 2012, 32 (2), pp.335-353 Aydogdu O, Pulat H Asymptomatic farmigration of an intrauterine device into the abdominal cavity: A rare entity CUAJ... was larger than the rearward If the intestinal segment necrosis was in the colon, we had to take a segment of colon out to make an artificial anus, clean the abdominal cavity and put drains after... female patients who had an IUD before and come for an examination and if we could not find an IUD in their uterus, then we had to scan their abdominal cavity to diagnose Aydogdu et al reported a