Hijab Pin Ingestions

We retrospectively reviewed the Hadassah Hebrew University Medical Center database, searching for patients 0 to 25 years old who presented because of foreign-body ingestion (International Classification of Diseases, Ninth Revision code 938). We selected hijab pin ingestion cases by manually reviewing these files and their abdominal radiographs. Data regarding demographics, signs and symptoms, anatomic location, medical management, and time from arrival to procedure were collected. Patients were excluded if no pin was found on chest and abdominal radiographs.

Time span from pin swallowing to arrival (pin to door time) was obtained from the ED files. When an exact time frame was not documented, we interpreted the following terms according to our estimate on the basis of our knowledge of arrival times to our ED: on the same day, 6 hours; briefly, 1 hour; a few hours earlier, 3 hours; and the day before, 24 hours. If time was stated specifically, we used the exact time lapse as mentioned.

Pin location was determined by ED physicians’ notes and was confirmed by reexamining plain films or endoscopy pictures. Pin location was divided into 5 main groups: pharynx, esophagus, stomach, small bowel, and colon.

We collected data regarding management of cases and categorized them according to the following categories: discharge, patient was discharged after ED evaluation was completed; observation, patient was admitted for medical follow-up and serial abdominal films; and intervention, any endoscopic or surgical intervention.

Demographic, clinical, and laboratory variables were summarized by standard descriptive statistics as means and SDs for continuous variables and as proportions for categorical variables. Student’s t test and the Mann–Whitney U test were used to assess differences between the groups for continuous variables. Proportional differences were assessed by using the χ² test, followed by Fisher’s exact test. Correlations were assessed by Pearson’s and Spearman’s coefficients as appropriate. Logistic regression analyses were used to build a model best for predicting the finding of an impaled pin. The statistical analysis was performed by using SPSS software 20.0 (IBM SPSS Statistics, IBM Corporation).

The study was approved by the local Institutional Review Board Committee at Hadassah Medical Center, Jerusalem, in accordance with the Declaration of Helsinki (0542–17-HMO).

Over the past years, patients with hijab pin ingestion in our center have been managed according to the clinical judgment of the attending GI specialist, with some opting a more conservative, delayed interventional approach on the basis of their clinical experience. To create a center-based policy, the data and analysis performed for this article were presented to our pediatric GI specialists. They were then asked to generate specific management recommendations depicting the delayed interventional approach. These recommendations were then compared to previous foreign body algorithms^2,4  to ensure similar structure and time intervals and were revised accordingly. We searched PubMed to address any previous publications on hijab pin ingestion using the phrases hijab pin, turban pin, hairpin, scarf pin, and straight pin. All articles were reviewed in the process of generating the proposed recommendations.

Between January 2007 and September 2018, ∼630 000 patients 0 to 25 years of age presented to our ED. Foreign-body ingestion accounted for 1558 (0.2%) visits. Of these, 208 (13.3%) presented because of hijab pin ingestion, with a total of 225 hijab pins (12 patients swallowed multiple pins: a total of 29 pins). The average patient age was 14.7 ± 4.1 years, and 88% of patients were girls. Analysis of patients who ingested multiple pins was performed according to the site of the most proximal pin. Demographic and clinical data are shown in Table 1. In Fig 2, we present the age distribution of the patients. Extracted Hijab pins were similar to previously reported pins: a sharp metallic pin ∼3.5 cm in length with a small plastic ball head.

The average pin to door time was 24 ± 49.5 hours (0.5–336 hours). Four patients had an unusually long delay to presentation (2–6 months) and were excluded from this analysis.

Ninety-three patients (44.7%) complained of abdominal pain or discomfort on presentation. Sixty-six patients (31.7%) had objective abdominal tenderness on physical examination, and one presented with abdominal guarding. Eighty-two patients (39.4%) were asymptomatic. Other patients presented with various nonspecific symptoms such as throat pain or shortness of breath.

All patients underwent plain radiography of the chest and abdomen. In 15 patients, an abdominal computed tomography (CT) scan was performed. In Table 1, we present pin location on arrival to the ED. The most common location for a pin on arrival was in the stomach (97 cases, 46.6%).

Because impaled pins (Fig 3) are the ones that have clinical consequence and necessitate endoscopic or surgical intervention, we examined the clinical course of this group of patients separately. Forty-two of the 225 pins (18.6%) were found to be impaled and penetrating the mucosal wall, 31 of which (73.8%) were impaled in the stomach (Fig 4). No association was found between age, sex, or any subjective symptoms and an impaled pin. Location in the stomach (odds ratio = 4.3 [95% confidence interval: 1.9–9.2]; P < .001) and abdominal tenderness on examination (odds ratio = 2.7 [95% confidence interval: 1.3–5.6]; P = .007) were strong independent risk factors for an impaled pin.

Three patients presented with a pin in the esophagus. One was removed endoscopically, and 2 spontaneously advanced through the GI tract with no complications.

Ninety-seven patients (46.6%) presented with 105 pins documented in the stomach by plain film on arrival. Three of these patients were found to have an additional 5 pins in the small bowel at the time of first imaging. The pin to door time was 29.2 ± 64.2 hours. Fourteen (14.4%) were discharged directly from the ED and have no documented follow-up. Of the 83 patients who were admitted for observation, 48 were discharged after a follow-up radiograph proved propagation of the pin, and 35 underwent an endoscopy after a follow-up radiograph failed to reveal spontaneous propagation. Thirty-one pins were proven to be impaled by endoscopy. The mean door to endoscopy time was 23.7 ± 27.1 hours (2–120 hours).

Seventy-one patients (34.1%) presented with 73 pins in the small bowel. Two patients had an additional pin in the colon at presentation. The pin to door time was 12.5 ± 26.7 hours. Forty patients were discharged, and 24 were admitted and discharged after a follow-up radiograph proved propagation of the pin. Six patients underwent an endoscopy, and in one patient, the pin was removed in an elective surgery. Door to endoscopy time was 18 ± 11.8 hours (6–39 hours).

Thirty-three patients presented with 34 pins in the colon. The pin to door time was 34.9 ± 33.0 hours. Twenty-three patients were discharged, and 9 were observed overnight. One patient underwent a colonoscopy, and one patient required manual removal of the pin under anesthesia.

Several complications or unique cases were observed. Importantly, no complications were observed in patients while under observation or awaiting an endoscopy. In one previously described case, a pharyngeal hijab pin penetrated the vertebral artery⁹  and was removed surgically. In 4 cases, the hijab pin was originally aspirated into the airway (as proven by a radiograph) and was later found in the GI tract. One patient presented with signs and symptoms of acute appendicitis but had a normal appendix visualized on a CT scan. When reviewing the CT scan by using bone window, a metal hijab pin could be differentiated from the surrounding contrast material in the proximal ileum (Fig 5). One patient presented 2 months after pin ingestion with mild abdominal pain, and the pin was removed surgically from the small bowel with no complications. One patient presented with mild abdominal pain shortly after ingestion. A CT scan revealed the pin penetrating the liver through the duodenum. This pin was removed endoscopically with no complications.

We present the largest cohort of hijab pin ingestion cases to date. Conservative management resulted in fewer endoscopies, when compared to current guidelines, without an increase in the rate of complications. In our study, location of the pin in the stomach and abdominal tenderness on physical examination were strong and independent risk factors for an impaled pin necessitating endoscopic intervention. On the basis of these findings, specific management recommendations for hijab pin ingestion in adolescents are suggested below.

Hijab pins were 13.3% of all foreign-body cases in our series, similar to rates reported in Muslim countries⁷  but higher than rates reported in Western countries.^10,11  A recent case series from the United Kingdom suggests that the prevalence of hijab pin ingestion in Western countries is changing.⁸ 

Management of straight pin ingestion is controversial, with recommendations spanning from conservative follow-up to surgical intervention.⁴  Ingested straight pins may either pass unnoticeably or penetrate the mucosa, necessitating endoscopic or surgical removal and potentially causing damage to adjacent organs. Because of a cited complication rate as high as 35%, current guidelines recommend removal of any sharp foreign body within reach of the endoscope.³  Contrary to this high complication rate, only one patient in our study (0.048%) required surgery, and only one patient had proven penetration of the liver, yet this did not have any effect on her clinical status. No other complications were observed. A similar rate of surgical interventions for hijab pin ingestions was presented in a previous study.¹² 

Straight pins, and more specifically hijab pins, are clearly underrepresented in the literature on which current guidelines are based.^10,13,14  Reilly et al¹³  included in their cohort various sharp object ingestions but few straight pins. In another study, only 3 of 244 cases were straight pins.¹⁰  Aydoğdu et al⁷  presented a cohort of foreign-body ingestion cases with an 18% incidence of hijab pins (32 pins). Their approach, as recommended by the guidelines, was that all sharp objects within reach of the endoscope should be removed if possible, and as such, all stomach pins were removed emergently. Therefore, although their study does suggest a low complication rate of hijab pin cases, it does not represent the outcome of a conservative management strategy.

In our study, 97 patients presented with a pin in the stomach and were therefore candidates for emergent endoscopic retrieval according to current guidelines. Adhering to our delayed interventional approach reduced the number of endoscopies to only 35, of which 31 patients did, in fact, carry an impaled pin. Managing patients with small-bowel pins according to these recommendations resulted in only 6 endoscopies, with an impaled pin found in 5 of the patients.

Although the signs and symptoms of hijab pin ingestion are nonspecific and vary from anxiety and throat pain to abdominal pain and true tenderness, they may be a valuable clue, focusing the clinician on the patients who may indeed require intervention, and should not be overlooked. We found that abdominal tenderness was an independent risk factor for an impaled pin, and this has been incorporated in our management recommendations. In a previous large cohort of hijab pin ingestion cases,¹²  only patients who denied abdominal pain and had a normal physical examination were conservatively managed. This makes their results less applicable to the general population arriving to the ED and potentially filters out the more severe patients. Importantly, even while including symptomatic patients with abdominal pain and tenderness in our study, none of these patients suffered any complications while under observation. This important finding emphasizes the safety of conservative management of patients with hijab pin ingestion.

According to current guidelines, sharp objects beyond the ligament of Treitz can be observed by serial radiographs, but this should be done in a hospital setting, and surgery is recommended if no passage is documented within 3 days.⁴  In our study, 50% of cases presented with the pin already in the small bowel or colon. Most of these patients were discharged, and in the 11-year period of the study, we noted no complications in this group and only one patient who needed surgical removal of an impaled pin. Although authors of previous studies on hijab pins have not proposed specific management for small-bowel pins,^7,12  we suggest inpatient observation for patients with abdominal tenderness and a pin beyond the stomach. Outpatient follow-up seems to be a safe option for patients who are asymptomatic.

The hijab pin is typically constructed of a 3.5-cm long metal body with a small round plastic head. Accidental swallowing occurs almost universally with the head facing inwards. Accordingly, Uçan et al¹⁵  found that in all 47 pin aspiration cases they presented, the distal end of the pin found in the lungs was the plastic head. This may explain the low number of pins impaled in the upper airway and esophagus. However, in the stomach, the pin may rotate and become impaled. The 29% rate for an impaled pin in our study is similar to a 27% rate (38 of 137) previously described.¹²  Once penetrated, the plastic head acts as a safety mechanism, lodging itself intraluminally on the mucosa and allowing for relatively easy endoscopic retrieval (Fig 3B). On the contrary, ingested sewing needles can transverse the mucosa into the peritoneal cavity.¹⁶ 

Despite the uneventful clinical course we described herein, hijab pins in the GI tract carry a small but significant risk for serious complications. The most serious complications occurred in patients with no adequate follow-up who carried an impaled pin for several months. Alkan et al¹⁷  presented a patient with right-sided hydronephrosis due to a hijab pin ingested 11 months earlier. Dalrymple et al reported a patient with a perforation of the duodenum and liver with a localized pus collection, who presented with mild abdominal pain 2 months after pin ingestion.¹⁸  There has been one report of death in a patient with hijab pin ingestion, although the details of this case are not clear.¹⁹  These cases reveal the importance of ensuring adequate follow-up for asymptomatic patients discharged from the hospital without proof of passing the pin. Although a CT scan should not be a routine part of the workup for ingested pins, we suggest considering an abdominal CT scan for any patient arriving with a long-standing impaled pin to assess for infectious and mechanical complications or if otherwise clinically indicated.

The following recommendations summarize our management of hijab pin ingestion in adolescent patients:

1. Esophageal pins: manage emergently according to current guidelines. Consider an additional radiograph for patients with a recent (1 hour) pin ingestion, without delaying preparation for an endoscopy, because many of these pins will pass spontaneously.

2. Stomach pins: admit patients for observation. Conduct an abdominal radiograph every 6 to 12 hours. Discharge once the pin has moved beyond the stomach and the patient is asymptomatic. If no progression is observed, plan for an endoscopy within 24 to 48 hours.

3. Abdominal tenderness: any patient with abdominal tenderness and a stomach or bowel pin should be admitted for observation. Plan for an endoscopy if no movement is observed within the first 6 to 12 hours.

4. Delayed presentation: obtain an abdominal CT scan of any patient arriving with a pin ingestion dating >2 to 3 weeks. Consider no contrast or use bone window to discriminate the pin from contrast material.

Criteria for discharge from the ED are as follows: (1) no abdominal tenderness on physical examination, (2) the pin is beyond the pylorus, and (3) adequate follow-up ensured (including a follow-up radiograph after 2–3 weeks).

Our study is limited by its retrospective nature. There is a potential for loss of follow-up of patients who later suffered from complications. However, we believe that this is unlikely because our hospital is the main referral center in Jerusalem for the Muslim community as well as for complicated GI and surgical pediatric cases. Another limitation is that this is not an interventional study, and the management recommendations we propose have not been validated prospectively.

Hijab pin ingestion is a unique clinical entity. The majority of patients affected are adolescent girls. Conservative management reduces the rate of endoscopy yet does not increase the rate of complications. Location of the pin in the stomach and abdominal tenderness on physical examination were strongly and independently associated with an impaled pin. In future guidelines specific management recommendations should be considered for adolescents with accidental ingestion of hijab pins.

We thank Nadav Levinger, MD, for his assistance in the data collection.

CT

computed tomography

ED

emergency department

GI

gastrointestinal