Background
Foreign body ingestion is a common emergency presentation, particularly in children. It is less frequent in healthy adolescents, yet remains a critical scenario when objects are sharp, bulky, or radiopaque. This case report describes the spontaneous passage of a metallic bullet casing that was accidentally ingested by an otherwise healthy teenager, emphasizing clinical decision-making, radiologic assessment, and patient outcome.
Case Presentation
A previously healthy adolescent presented after an alleged accidental swallow of a small metallic object. The patient reported immediate mild throat discomfort without choking, coughing, drooling, or stridor. There were no abdominal or chest symptoms. Vital signs were stable, and there was no airway compromise.
Initial evaluation included a focused history and physical examination, followed by radiographic imaging. Plain radiographs identified a metallic object consistent with a bullet casing located in the esophagus, with no signs of obstruction or perforation. Given the small size, blunt morphology, and absence of alarming features (drooling, dysphagia, or severe pain), the team considered a conservative management approach with close observation.
Management and Monitoring
The patient was admitted for observation with instructions for fasting and gradual diet advancement as symptoms allowed. Serial radiographs were scheduled to track the object’s progression. The care team emphasized patient and caregiver education about warning symptoms such as increasing throat pain, vomiting, fever, chest pain, or sudden inability to swallow, which would necessitate urgent reevaluation.
Over the ensuing 24–48 hours, serial imaging demonstrated slow transit through the gastrointestinal tract without developing signs of obstruction. The adolescent remained clinically stable with improving mild throat symptoms but no systemic signs. No endoscopic retrieval was performed because there was no evidence of esophageal impaction, airway compromise, or request for intervention, and the patient demonstrated progressive passage on imaging.
Outcome
The bullet casing progressed through the gastrointestinal tract and was expelled in the stool within several days. The patient reported no complications and returned to normal activities with resolved symptoms. Follow-up at clinic visit confirmed no late sequelae, such as perforation or stenosis, and advised continued attention to any delayed symptoms.
Discussion
This case highlights several key considerations in adolescent foreign body ingestion. First, not all ingested metallic objects require immediate endoscopic removal; clinical status, object characteristics, and location guide management. A small, nonsharp, radiopaque object in a patient without airway or digestive tract compromise may pass spontaneously with careful observation and serial imaging.
Second, radiographic monitoring is essential to ensure visibility and track progression. In contrast to enteric or airway foreign bodies that pose higher immediate risk, ingested bullet casings in stable patients may be managed conservatively when the risk of perforation or obstruction is low.
Third, patient education and clear discharge instructions are critical. Parents and adolescents should recognize warning signs that demand urgent evaluation, including drooling, dysphagia, chest or abdominal pain, fever, or persistent vomiting.
Conclusion
Spontaneous passage of an accidentally ingested bullet casing can occur in healthy adolescents when the object is small, blunt, and radiopaque, and when there are no signs of obstruction or perforation. With careful observation, appropriate imaging, and patient education, conservative management can lead to uncomplicated outcomes. This case contributes to the evolving understanding of pediatric and adolescent foreign body management and supports individualized decision-making in similar presentations.
