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Intrauterine contraceptive device: cause of small bowel obstruction and ischaemia

We present an interesting case of small bowel obstruction caused by an intrauterine contraceptive device (IUD) inserted in the 1960s. A 79-year-old female presented to the emergency department with sudden onset of severe epigastric pain in the early hours of the morning. This was accompanied by vomiting and the inability to pass flatus. However, she denied fevers, chills or other infective symptoms. Significant past history included the implantation of an IUD in the 1960s. This was never removed as it was assumed to have fallen out during micturition. Physical examination revealed abdominal tenderness of the epigastric region on palpation, but an otherwise soft abdomen with bowel sounds. Urinalysis showed no signs of a urinary tract infection. Blood tests were unremarkable apart from a white cell count of 17.7 × 10/L and lactate level of 2.4 mmol/L. Computed tomography scan revealed a proximal to middle small bowel closed loop obstruction with ischaemia secondary to an IUD (Fig. 1). The patient was subsequently taken to the theatre, 15 hours after the onset of symptoms, for laparotomy and removal of IUD (Fig. 2). The diagnosis was confirmed intraoperatively with the finding of an IUD looped around the middle small bowel causing ischaemia (Fig. 2). Sixty centimetres of ischaemic bowel was resected and the patient recovered without incident. She was discharged 5 days after her operation. IUDs are the most widely used method of reversible birth control in the world. Complications such as infection, pain, bleeding and uterine perforation are well known. The incidence of perforation has been estimated to be less than 0.1%. Risk factors include a retroverted uterus, insertion during the post-partum period and inadequate insertion technique. The majority of perforations occur during insertion or later on by forceful uterine contractions pushing the device into the pelvic and abdominal cavities. Once in the abdominal cavity, most devices will remain indefinitely. A minority may become embedded in the omentum, while others can cause peritoneal reaction and adhesion formation. The majority of IUD dislocations have minimal complications but serious outcomes have been reported. These include visceral perforation, erosion of the bladder and bowel perforation. Cases of small bowel obstruction from transmigrating IUD are rare. Those that have been reported usually result from IUDassociated actinomycosis infections. In contrast, this case showed no evidence of infection, rather obstruction was caused by direct strangulation of the small bowel by the IUD. Furthermore, the obstruction occurred from an IUD placed nearly 50 years prior. This is particularly unusual as most visceral complications are reported within a median time period of 17 months, with reported time frames varying from 4 weeks to 13 years. Several methods have been described for removal of an IUD from the viscera. The two current accepted approaches are the use of laparoscopy or laparotomy. This is to due to the potential for further perforation and obstruction associated with other methods. Given the unusual pathology of this case, a laparotomy approach was undertaken for greater access. Fig. 1. Computed tomography coronal of intrauterine contraceptive device in situ.