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.
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BOWEL OBSTRUCTION CAUSED BY AN INTRAUTERINE DEVICE INTO THE ABDOMEN CAVITY: A CASE REPORT AT
103 MILITARY HOSPITAL
Ho Chi Thanh 1 ; Dang Viet Dung 1 ; Nguyen Van Thanh 1
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 recovered well, fed on the 4 th day and was discharged on the 7 th 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 3 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
1 103 Military Hospital
Corresponding author: Ho Chi Thanh (hochithanhbv103@gmail.com)
Date received: 13/07/2019
Date accepted: 23/08/2019
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- The patient had been treated according
to mechanical obstructive obstruction
regimen at a district hospital for 3 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
* Medical history:
- No times being to have an abdominal
surgery in the past
- Having an IUD fitted about 30 years
ago
* Medical examination:
- 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
- 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
- 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)
- 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
Before operation
After operation
72 hours
Creatinine 125.8 µmol/L 61.2 µmol/L
Figure 1: Abdominal X-ray
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Figure 2: Abdominal computed
tomography scan
Figure 3: The IUD in her abdomen
Figure 4: IUD and a piece of necrotic
intestines
* Diagnosis before surgery: Peritonitis
caused by an IUD into the abdominal
cavity
* 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
- 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 6 hours and treated at the intensive care unit
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
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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
1 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 5 years [2] She felt
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
2 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
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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
intra-abdominal IUD The patient underwent a
laparoscopic surgery to check and remove
IUD while it was entering the sigmoid
colon wall [8]
3 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 do 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
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Penetration of the descending colon by a
J Korean Soc Coloproctol 2010, 26 (6), pp.433-436.
3 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
4 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.
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far-migration of an intrauterine device into the abdominal cavity: A rare entity CUAJ 2012, 6 (3), pp.134-136
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forgotten migrated intrauterine contraceptive device is not always innocent: A case report Case Reports in Medicine 2010, pp.1-3
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obstruction caused by migrated intrauterine contraceptive device: A case report Biomed
Res 2017, 28 (22), pp.1-3
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contraceptive device in peritoneal cavity invading sigmoid colon Journal of Case Reports 2014, 4 (1), pp.193-195