Background
Accidental ingestion of foreign objects is a common reason for pediatric and adolescent emergency presentations. While most cases involve children or adults with predisposing factors, rare instances occur in healthy adolescents. Metallic objects, including bullet casings, pose unique clinical considerations due to their shape, sharpness, and potential for impaction or perforation. This case report describes a healthy adolescent who spontaneously passed an ingested metallic bullet casing, emphasizing clinical decision-making, observation, and follow-up in foreign body ingestion.
Case Presentation
A previously healthy adolescent presented to the emergency department after a witnessed event of swallowing a small metallic object during a recreational activity. The patient denied immediate airway symptoms, choking, or respiratory distress. There was no history of prior esophageal or gastrointestinal disease, and no predisposing neurodevelopmental or psychiatric factors were identified that would increase risk for pica or intentional ingestion.
Initial assessment included a focused history, physical examination, and plain radiographs. Imaging demonstrated a radiopaque, cylindrical object consistent with a bullet casing located in the stomach with no evidence of active obstruction or perforation. The patient was hemodynamically stable, tolerating oral intake, and without abdominal tenderness or signs of peritonitis.
Management and Observation
In the absence of symptoms suggesting complications and given the object’s likely passage trajectory, a conservative management approach was chosen. The patient was admitted for observation with serial abdominal examinations and periodic imaging to track progression through the gastrointestinal tract. A plan was made to manage expectantly unless red flags emerged, such as persistent pain, vomiting, fever, gastrointestinal bleeding, or signs of obstruction.
Over a 24–48 hour observation window, the adolescent remained clinically well with no new symptoms. Serial imaging demonstrated gradual progression of the object through the small bowel into the colon, consistent with spontaneous transit. No signs of special risk, such as ileal perforation, were detected on follow-up imaging.
Ultimately, the bullet casing was passed per rectum without complication. The patient reported no residual abdominal pain or discomfort. Post-pydoscopic evaluation was not necessary for this spontaneous passage, given the lack of persistent symptoms and normal imaging trends. Discharge instructions included warning signs warranting prompt return to care and guidance for future ingestion prevention.
Discussion
This case highlights several important considerations in the management of ingested foreign bodies in adolescents. First, the likelihood of spontaneous passage is higher for objects with smooth surfaces, non-sharp edges, and moderate size, provided there are no symptoms or risk factors for obstruction or perforation. Bullet casings, while cylindrical, can be sharp at the edges and may cause mucosal irritation; however, in this case, the object did not precipitate complications during transit.
Second, patient selection for conservative management requires a careful assessment of the object’s radiopacity, location, and the presence or absence of symptoms. Esophageal foreign bodies typically require urgent intervention due to a higher risk of impaction or perforation, whereas gastric or intestinal objects in asymptomatic patients may be observed with timely follow-up. Third, serial imaging remains a key component of safe observation, ensuring the object’s progression and early detection of potential complications.
Finally, this report underscores the importance of counseling adolescents and families about risks associated with foreign body ingestion and preventive strategies, including supervision during high-risk activities and avoiding ingestion of non-food items. While rare in healthy teens, accidental ingestion can occur, and a structured approach to evaluation and management minimizes adverse outcomes.
Conclusion
In select adolescents with ingested foreign bodies, spontaneous passage can occur without complications under careful observation. Clinicians should balance the object’s characteristics, patient stability, and available resources when deciding between observation and intervention. This case adds to the growing body of literature supporting conservative management in well-selected patients and contributes practical insights for emergency medicine and pediatric practice.
