Unusual attempted suicide by plaster ingestion

【关键词】  suicide;plaster,ingestion;,gastrotomy

    Unusual attempted suicide by plaster ingestion

 ［Abstract］  The following report represents an adult male with underlying bipolar disorder who presented to our emergency department after an unusual attempted suicide by ingesting a solution composed of plaster in water. With diagnosis of gastric outlet obstruction, the patient was underwent gastrotomy and finally released without any complication. Although accidental plaster ingestion has occasionally been discussed, intentional ingestion in an apparent suicide attempt has been rarely reported.

    ［Key words］  suicide;plaster ingestion; gastrotomy

    INTRODUCTION

    Plaster of Paris, or simply plaster, is an easily available and a widely used building material ba[x]sed on calcium sulfate hemihydrate, nominally （CaSO4）2 H2O［1］. It is fine, white to gray colored powdered solid with no odor［2］ and is generally created by heating gypsum ［CaSO4 （H2O）［2］, Hydrated Calcium Sulfate］［1］. When dry plaster powder is mixed with water, it re-forms into gypsum, initially as a paste but eventually drying into a solid［1］. Plaster expands while drying, and then contracts slightly just before hardening completely.

    Plaster is classified as “non-hazardous materials” in the classification of chemical safety and waste management manual［3］ and is not listed in the National Occupational Health and Safety Commission’s （NOHSC） List of Designated Hazardous Substances. Plaster is also considered to be slightly toxic for mammals with acute oral toxicity （LD50） of 5000 mg/kg in rats［4］. Data on chronic human exposure, genotoxicity, carcinogenicity and reproductive toxicity is not available, but acute exposure to calcium sulfate hemihydrate has resulted in skin, eye and respiratory irritation［4］. Generally, ingestion of the plaster is unlikely to occur, but may cause gastric disturbances［2］. It seems that the plaster is non-toxic and no harmful effects expected （no data on acute toxicity was found）; however, since the chemical readily absorbs moisture and hardens, ingestion of a sufficient quantity could lead to mechanical obstruction of the gastrointestinal tract, especially the pyloric region, which may require surgical intervention［2］. It also may cause irritation of the mouth and gastrointestinal tract［4］.

    However, despite of these notes, case reports of plaster ingestion in suicide attempt, as an uncommon and odd method of suicide, have not appeared in the medical literature frequently. We reported a case of gastric outlet obstruction due to plaster ingestion in a suicidal attempt, which was successfully treated by surgical removal of the hardened plaster masses.

    CASE HISTORY

    A 48-year-old-male patient attempted suicide by ingesting a large amount （more than three glass≥750 ml） of a solution composed of plaster in water. The patient had experienced mild abdominal cramping

    1 Department of Surgery, Shariati Hospital,Tehran University of Medical Sciences,Tehran-14114,Iran

    2 Department of Surgery, Isfahan University of Medical Sciences,Isfahan,Iran

    Correspondence to Ali Gholamrezanezhad, Department of Surgery, Tehran University of Medical Sciences, Shariati Hospital, Northern Kargar St., Tehran 14114, Iran

    Tel:+98-21-09122107037,Fax:+98-21-8026905

    E-mail:gholamrezanejhad@razi.tums.ac.ir

    （restricted to the epigasteric region） and watery diarrhea following ingestion. Ten days after, he developed melena, nausea, and vomiting. On arrival at the emergency ward, two weeks post-ingestion, he was alert, and was admitted suspecting for bowel obstruction. Vital signs were blood pressure 120/70 mm Hg, temperature 36.6 ℃, heart rate 76/min, and respiratory rate 16/min. On clinical examination, there was no abdominal distention, tenderness or rebound tenderness, and also no abdominal mass was palpable.

    Bowel sounds were normal. No other signs were detected in the examination of the other organs. Although a urine comprehensive drug screen was not obtained, he did not present with a toxic syndrome consistent with other ingestants.

    A subsequent psychiatric consultation revealed that the patient was an old known-case of bipolar affective disorder since few years ago, who was under medical treatment using trifluoprazine, carbamazepine and biperdine, with history of 11 times hospitalization in different psychiatric wards. No substance abuse was defined in his psychiatric history. There were no other prominent features in his medical history and no history of abdominal surgery was present.

    His complete blood picture revealed hemoglobin of 17.2 Gm/dl, WBC count 9.3×109/L and ESR 3 mm/1st hour. Hematological and biochemical analyses （including serum calcium and other electrolytes, liver functions, blood glucose, blood urea, serum creatinine, serum amylase, and also urine analysis） and chest radiograph were normal. A plain abdominal X-ray on admission showed few large and calcified intraluminal space-occupying lesions in the stomach suggestive of few masses of gypsum （Figure 1）.

    Figure 1  Plain abdominal X-rays showing large intragastric radioopaque plaster masses

    Endoscopic examination was carried out, which showed the stomach containing few masses of gypsum, which were not removable by endoscopy. Endoscopy also showed that the plaster ingestion had caused direct erosive injury to the upper gastrointestinal tract. Considering the clinical presentation and endoscopic and radiological findings, a diagnosis of gastric outlet obstruction as a result of intragasteric hardening of the ingested plaster solution was made and gastrotomy was recommended.

    At our hospital, supportive therapy including fluid resuscitation, and careful attention to acid/ba[x]se and electrolyte management provided the basis of therapy［5］. After these primary measurements, the patient was explored electively and during operation three masses of plaster were totally removed （measuring 3 cm×3 cm×3 cm, 5 cm×3 cm×3 cm and 7 cm×7 cm×7 cm） by an anterior gastrotomy （Figure 2）. Following removal of the gypsums, the antrum was observed with a single ulcer, of which a biopsy was obtained. The operative time was 65 minutes. Postoperative period was smooth. The patient resumed oral intake on the second post-operative day and returned to normal activity on the 3rd post-operative day. He was then discharged and referred to a psychiatrist for evaluation, where he was advised treatment for his emotional disorder.

    Figure 2  Removal of intragastric masses measuring 3 cm×3 cm×3 cm,5 cm×3 cm×3 cm and 7 cm×7 cm×7 cm following anterior gastrotomy

    Histological examination of the gastric ulcer biopsy revealed chronic gastritis, but there was no evidence of malignancy.

    RESULTS AND DISCUSSION

    Calcium sulfate hemihydrate has been used for many years and is still used extensively in both industrial and consumer areas. While bowel obstruction has been considered as a consequence of plaster ingestion［2］, documentation of recent such case reports in the medical literature are lacking and therefore, we report such a case for the first time to our knowledge. Our investigation of literature identified one large review on suicide attempt by plaster ingestion in an Iranian national journal （Iranian Journal of Legal Medicine）［6］. In this only previous study, the authors reviewed demographic features and endoscopic results of forty patients admitted to a general hospital in one of the western states of Iran （Kordestan）, with a history of plaster ingestion between 1997 and 2000. Twenty-three of the patients （57.5%） were female and 17 （42.5%） were male. The majority of patients （45%） were in the range of 10~19 years, which correlates well with previous data on the prevalence of suicidal behavior. 37.5% of the victims were student and 35% were housekeeper. All of the suicide attempts were by ingestion and in the form of water soluble. In their report of these forty cases, Yeganeh,et al. found that the most common symptom was abdominal pain （42.5%） followed by vomiting （15%）. The most commonly reported sign was a palpable abdominal mass, which was detected in the 17.5% of the patients. Fifty percent of patients had no remarkable sign or symptom. No toxicological data were given, but there were no remarkable abnormality in the laboratory and biochemical analysis of the patients.

    Endoscopy was attempted in 6 patients, which revealed presence of hard masses of plaster in 4 patients. No endoscopic evidence of esophageal or gastric erosion was reported, which is not in agreement with previous data［2］. Gastric washing was the most important therapeutic measures in these cases. Half of the patients had been treated by gastric washing using at least two liter of normal saline. In this subgroup of patients only one case required surgery （the only case in whom gastric washing was performed by less than two liter of normal saline）. Totally, seven victims were underwent laparotomy for removal of the masses, of which only one patient had been treated previously by the gastric washing method. Thirty nine of the patients survived without any remarkable sequel, and only one died （which was due to simultaneous ingestion of an unknown organophosphate toxin）. The mean interval time of release after admission was 3~ days in whom had not been undergone surgery and 7 days in whom laparotomy had been performed.

    ba[x]sed on these findings, it was stated that it seems highly advantageous to perform gastric washing with more than two liter of normal saline solution as the primary therapeutic measure for plaster ingestion. It is important to quickly identify if a patient has ingested plaster and perform gastric washing early to prevent the hardening of the paste in the stomach and foreign body formation. The authors also concluded that the time between ingestion and initiation of treatment can predict outcome. Hence, most of the patients can be initially treated conservatively with continuous follow up by daily examination. The mechanism responsible for performing gastric washing by normal saline is that the salt will lengthen the setting time of the plaster and also appreciably reduces the strength of the final product［6,8］,which in turn provide the opportunity for elimination and destruction of the ingested plaster by the bowel transit and contraction.

    Generally, mortality is extremely low and there is no specific treatment［6］. Therefore, the management is initially supportive［6］. Although dissolution, lavage and gastric washing, suction, and （if available） mechanical fragmentation using pulsating jet of water can be helpful in most cases and are the main challenge, but in some cases surgical intervention is mandatory, if there is a dense or irremovable mass in the stomach［6］. More recently, the same author and his colleagues reported a case of a 37 year-old woman presenting with plaster ingestion and gastric outlet obstruction, who underwent surgery. At six months follow-up the patient was fully recovered. The authors concluded that plaster has no toxic or erosive effects. Endoscopic or surgical removing of such material was recommended and also the previously mentioned suggestions were again repeated in this case report［9］. These explanations are also valid for our case. The symptoms in the case presented are identical to those reported by Yeganeh and his colleagues. Gastric washing in our case was not performed, because hardening of the plaster and gastric outlet obstruction has already been occurred and therefore the initial treatment was only a surgical intervention.

    Furthermore, almost all of these true attempts were not life threatening, suggesting that the reports were attempts to communicate the hardships of lives［6］. It seems that they were false attempts-ideation rather than a concrete act to end life. However, the lack of knowledge about plaster’s potential dangerousness, its widespread availability, and absence of early symptoms of systemic toxicity make it highly dangerous to those who take it during parasuicidal behavior. Also it was hypothesized by Yeganeh,et al.that most adolescents are naive about the complications of plaster ingestion.

    Suicide is a crime under Islamic law and attempts may lead to prosecution［10］. Nevertheless, it remains a major problem for Turkey, Uzbekistan and other central Asian countries［10］.The suicide of a young Muslim was reported in Australia［10］. The authors observed that the family was rejected by the local Islamic community because of the stigma associated with this event. Although compared to Western industrialized countries the number of suicides in Iran is very low, during the last two decades suicide has been on the rise［11］. For example from 1989 to 1993 the number of suicides in the country doubled whereas the population did not double［11］.

    Only in Ilam Province the number of suicides in 3 years （from 1989 to 1991） has increased by 16 times［11］. However, there are no reports concerning this matter of suicide pouring in from other parts of Iran. In fact, such occurrences rarely do occur in Iran and there is nothing in our culture that can explain this method of suicide. In such cases another possible explanation for the ingestion of plaster could be syndrome of PICA. PICA is the compulsive eating of non-food substances but it should be kept in mind that it is repeated over a sustained period of time［12］.Therefore, these single episodes of plaster ingestion can not be interpreted as PICA or any eating disorder. Also there are not any other side effects that these people are attempting to achieve （pleasurable feelings, loss of weight, etc.）.

    CONCLUSION

    Plaster ingestion is a relatively uncommon and odd method of suicide attempt. However, it does cause significant morbidity. The complications are predominantly due to physical obstruction rather than chemical or erosive injury. No specific treatment is available and the recommended treatment is to institute supportive measures initially. For those presenting soon after ingestion, gastric washing is a reasonable approach. However, in the presence of mechanical bowel obstruction, surgical intervention is necessary. As on forensic implications, it could be concluded that if seen at autopsy, plaster in the GI tract suggests a psychiatric condition and raises the possibility of suicide. Unless there is an obvious physical explanation for death （ruptured stomach,etc.）, then it is important to look for another explanation for death （drugs, toxins,etc.）.

    ACKNOWLEDGEMENTS

    The authors wish to thank Dr. Somaye Arabzade and Dr. Rozana Kazemi for their co-operation.

    REFERENCES

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    3. Chemical safety and waste management manual. University of Alabama at Birmingham, department of occupational health and safety, chemical safety division. 2002 edition.

    4. MATERIAL SAFETY DATA SHEET. Merlex Stucco, Inc. 2004.

    5. Clinical management of poisoning and drug over dosage. Haddad, Shanon. Winchester, 3rd edition，1998.

    6. Yeganeh R, Rafie N, Kazemi A, Dortaj F, Ahmadi M. Ingestion of plaster: a new and strange method of committing suicide in Lorestan province. Iranian Journal of Legal Medicine，2003，9: 85-89.

    7. Lecrubier Y. The influence of comorbidity on the prevalence of suicidal behaviour. Eur Psychiatry, 2001, 16（7）:395-9.

    8. Plaster Master Industries. U.S. Gypsum. Plaste Fundamentals,101,2.

    9. Yegane RA, Bashashati M, Bashtar R, Ahmadi M. Gastrointestinal obstruction due to plaster ingestion: a case-report. BMC Surg, 2006,16, 6: 4.

    10. Saxby Pridmore and Mohamed Iqbal Pasha. Psychiatry and Islam. Australasian Psychiatry,2004,12（4）: 380-385.

    11. Somayeh Askari. Women, Main Victims of Suicide in Iran. Farhang-e Tose’e, Monthly Magazine,1998, 37-42.

    12. Walker AR, Walker BF, Sookaria FI, Cannan RJ. Pica. J R Soc Health,1997, 117（5）: 280-284.

    （Editor HOU）

作者： Ahmad-Reza Sorush1，Mehran Nasr-Esfahani1，Mohammad-Reza Hakimian1，Ali Gholamrezanezhad1，Sepide Madhkhan2