Keine Tabletten im Blister: Perforation nach Verschlucken von Tabletten im Blister

Zusammenfassung

Hintergrund: Versehentlich verschluckte Tabletten in sehr scharfkantigen Blistern können Perforationen im Gastrointestinaltrakt auslösen, die sich dann erst nach Ausbildung einer Mediastinitis oder Peritonitis klinisch offenbaren. Die Letalität ist hoch. Patienten: Wir haben bei 2 kognitiv eingeschränkten Patienten je eine Ösophagus- und eine Ileumperforation gesehen. Ergebnisse: Trotz operativer Sanierung verstarb der Patient mit Ösophagusperforation 3 Wochen später im Multiorganversagen. Die Patientin mit Ileumperforation überlebte eine Sepsis nach wiederholten Eingriffen. Schlussfolgerung: Als Konsequenz wurde eine Dienstanweisung für den gesamten Krankenhausverbund umgesetzt, welche die Ausgabe von Tabletten im Blister am Patientenbett untersagt. Weitere Fälle traten seitdem nicht mehr auf.

Abstract

Background: Pills in sharp packaging that are accidentally swallowed (blisters) can cause perforations in the gastrointestinal tract, which are only clinically apparent after the emergence of mediastinitis or peritonitis. Mortality is high. Patients: We have seen two cases in cognitively limited patients, one with oesophageal and one with ileal perforation. Results: Despite surgery, the patient with oesophageal perforation died 3 weeks later of multi-organ failure. The patient with ileal perforation survived sepsis after multiple procedures. Conclusion: As a consequence, a hospital-wide policy was implemented prohibiting the issue of tablets in blister packaging at the bedside. No more cases have emerged since that time.

Schlüsselwörter

Blister - Darmperforation - Notfalloperation - Patientensicherheit - Fallbericht

Key words

blister-pack - bowel perforation - patient safety - emergency operation - case report

• Literatur

• 1 Goh BK, Chow PK, Quah HM et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006; 30: 372-377
• 2 Prokop A, Reinauer KM, Chmielnicki M. Lohnt sich ein zertifiziertes Zentrum für Alterstraumatologie?. Z Orthop Unfall 2015; 153: 306-310
• 3 Gupta NM, Gupta V, Gupta R et al. Esophageal perforation caused by a blister-wrapped tablet. Asian Cardiovasc Thorac Ann 2002; 10: 87-88
• 4 Coulier R, Rubay R, van den Broeck AR et al. Perforation of the gastrointestinal tract caused by inadvertent ingestion of blister pill packs: report of two cases diagnosed by MDCT with emphasis on maximal intensity and volume rendering reformations. Abdom Imaging 2014; 39: 685-693
• 5 Campos Franco J, López Rodríguez R, Martínez De Alegría A et al. [Esophageal perforation after ingestion of a blister-wrapped tablet]. Gastroenterol Hepatol 2011; 34: 515-516
• 6 Bosson V, Schnyder JM, Tschopp JM. Foreign bodies and hemoptysis: about danger of ingesting blister-wrapped tablets. Rev Med Suisse 2011; 13: 798-801
• 7 Dutta U, Gupta NM, Nagi B, Singh K. Blister pack ingestion resulting in esophago-pleural fistula. Indian J Gastroenterol 2001; 20: 79-80
• 8 Wecksell A, Lane E, Greenfield E. Odynophagia caused by inadvertent blister pack ingestion: a case report. Otolaryngol Head Neck Surg 1995; 112: 747-749
• 9 Lurton A, Ntiruhungwa J, Saillant H et al. Stomach perforation by a blister-wrapped capsule. N Engl J Med 1996; 335: 754
• 10 Yao SY, Matsui Y, Shiotsu S. An unusual case of duodenal perforation caused by blister pack. Int J Surg Case Rep 2015; 14: 129-132
• 11 Crowley LV, Bretzke ML. Bowel perforation from ingested unit dose blister-pack. Am J Gastroenterol 1988; 83: 1011-1012
• 12 Sato H, Endo T, Tajima K et al. A rare case of perneal pain: intestinal perforation caused by a press-through package. Anesth Analg 1992; 75: 456-457
• 13 Norstein J, Krajci P, Bergan A et al. Intestinal perforation after ingestion of a blister-wrapped tablet. Lancet 1995; 346: 1308
• 14 Fulford S, Tooley AH. Intestinal perforation after ingestion of a blister-wrapped tablet. Lancet 1996; 347: 128-129
• 15 Gupta V, Manikyam SR, Gupta R et al. Pelvic abscess after ingestion of blister-wrapped tablet. Am J Gastroenterol 2002; 97: 2142-2143
• 16 Ishikura H, Sakata A, Sakai Y et al. Intestinal perforation due to ingestion of blister-wrapped tablet in a press-through package. Am J Gastroenterol 2003; 98: 1665-1666
• 17 Fierens K, van Outryve L, Kint M. Bowel perforation from ingested blister-pack. Acta Chir Belg 2007; 107: 564-565
• 18 Tai AW, Sodickson A. Foreign body ingestion of blister pill pack causing small bowel obstruction. Emerg Radiol 2007; 14: 105-108
• 19 Tadic M, Kujundzic M, Babic Z et al. Acute lower gastrointestinal bleeding after ingestion of blister-wrapped tablet. Am J Gastroenterol 2007; 102: 2863-2865
• 20 Doman H, Ohara M, Noguchi M et al. Inadvertent ingestion of a press-through package causing perforation of the small intestine within an incisional hernia and panperitonitis. Case Rep Gastroenterol 2011; 5: 391-395
• 21 Sasko B, Butz T, Winnekendonk G et al. Bowel perforation because of ingestion of a blister-wrapped tablet after post-interventional coronary perforation. Dtsch Med Wochenschr 2012; 137: 2637-2640
• 22 Orry X, Balaj C, Lecocq S et al. CT diagnosis of small bowel perforation by ingestion of a blister pack: two case reports. Diagn Interv Imaging 2014; 95: 101-103
• 23 Al-Ramahi G, Mohamed M, Kennedy K et al. Obstruction and perforation of the small bowel caused by inadvertent ingestion of a blister pill pack in an elderly patient. BMJ Case Rep 2015; 2015 pii: bcr2015212822