Small bowel perforation due to a plastic bread bag clip: the case for clip redesign

Complications of ingested plastic bread bag clips include small bowel perforation, obstruction, dysphagia, gastrointestinal bleeding and colonic impaction. There have been at least 10 cases of small bowel perforation reported in the published literature. The present paper reports this unusual cause of bowel perforation, which we believe could be prevented by improving the design of this relatively modern device or even by changing the method of sealing bread bags altogether. Interestingly, the date on the offending bread bag clip preceded the presentation of the patient by 2.5 years.