Chronic Pica Resulting in Perforative Peritonitis: A Case Report

Foreign body (FB) ingestion is a frequent clinical presentation, particularly among children and individuals with intellectual disabilities. However, recurrent ingestion associated with pica represents a high-risk subset, often leading to cumulative gastrointestinal injury, operative complexity, and increased mortality. We report the case of a 23-year-old male patient with severe intellectual disability who presented with abdominal pain and distension of five-day duration. The patient had a significant history of recurrent FB ingestion, predominantly metallic objects, and his status was post prior surgical intervention. One year prior, he had undergone emergency laparotomy for cecal perforation secondary to ingestion of a metallic FB. On current evaluation, imaging revealed features of small bowel obstruction with suspected perforative peritonitis and multiple radio-opaque FBs. Exploratory laparotomy demonstrated extensive intra-abdominal pathology, including 12 sealed small bowel perforations, enteroenteric fistulae, and dense adhesions involving the small bowel, transverse colon, and stomach. Numerous FBs were identified, including batteries, screws, bolts, nuts, zippers, wooden sticks, and hair. A 60 cm segment of diseased small bowel was resected, and a double-barrel jejuno-ileostomy was performed in view of severe contamination and hemodynamic instability. Postoperatively, the patient required mechanical ventilation and inotropic support, but developed rapidly progressive septic shock leading to multi-organ dysfunction syndrome (MODS). The patient expired on postoperative day one. This case illustrates the pathophysiological progression of chronic pica, where recurrent ingestion leads to cumulative bowel injury, adhesions, fistula formation, and multiple perforations. It highlights the significant surgical challenges and poor prognostic factors, including delayed presentation, prior surgery, and severe intra-abdominal contamination. Notably, the case underscores a critical preventive failure, as the absence of sustained psychiatric intervention allowed recurrence and progression to fatal complications. Severe, recurrent pica should be recognized as a high-risk condition with potential for catastrophic gastrointestinal injury and mortality. Early identification, structured psychiatric follow-up, and a multidisciplinary preventive approach are essential to reduce recurrence and improve outcomes.