Strangulated intestinal obstruction caused by ectopic intrauterine device: a case report

Abstract

An intrauterine contraceptive device (IUCD) is a widely utilized contraceptive method. However, in rare instances, it may lead to severe complications such as strangulated intestinal obstruction. This paper presents a case involving an elderly female patient who developed acute abdominal pain and was subsequently diagnosed with strangulated intestinal obstruction attributed to an ectopic IUCD. The patient’s initial symptomatology included upper abdominal pain and severe vomiting, which led the clinician to perform only an upper-abdominal CT scan, yielding no significant findings. Following three days of conservative management, the symptoms persisted without relief. The patient continued to experience abdominal pain, accompanied by abdominal distension, and a cessation of both flatus and bowel movements. Consequently, a comprehensive abdominal CT scan was performed, revealing bowel obstruction with peritonitis. An urgent laparotomy was subsequently undertaken. Due to the necrotic condition of the bowel, a resection of the affected segment was performed, followed by a one-stage end-to-end intestinal anastomosis after the removal of the intrauterine device (IUCD). By the ninth postoperative day, the patient had recovered sufficiently to be discharged from the hospital. This case underscores the importance for women with an IUCD to regularly assess the device’s position and depth to prevent serious complications. It is also advisable to remove the IUCD promptly upon reaching the end of its effective lifespan or following menopause. Clinicians should be vigilant in monitoring and addressing abdominal pain in women with an IUCD.

Background

The intrauterine contraceptive device (IUCD) is popular for its reliable and long-lasting contraceptive effectiveness and is widely used [1]. Complications are uncommon, with typical issues being irregular bleeding, pain, and infection. And rare complications include pregnancy with the device, uterine perforation, and potentially life-threatening situations [2]. Strangulated intestinal obstruction from an ectopic IUCD is extremely rare. We present a case of intestinal obstruction and necrosis in an elderly woman caused by an ectopic intrauterine device in the abdominal cavity, offering insights for diagnosing and treating acute abdominal pain in elderly women.

Case presentation

A 72-year-old woman came to emergency department of the 991hospital with upper abdominal pain and severe vomiting for three days. On physical examination, her vital signs were stable (pulse rate: 90 beats per minute, blood pressure: 132/81 mmHg, temperature: 36.5 °C). Abdomen was soft, without muscle tension. And there was tenderness in the upper abdomen without rebound pain. She had no other symptoms like palpitations, chest tightness, fever, or diarrhea. An upper-abdominal CT scan showed no abnormalities. She received symptomatic and supportive treatments, including anti-inflammatory medication, fluid infusion, and pain relief. Following three days of conservative management, the patient continued to experience abdominal pain, accompanied by abdominal distension, and absolute constipation (absence of passage of flatus and stools). To further elucidate the underlying cause and determine appropriate treatment, the patient was admitted to the general surgery department. An urgent comprehensive abdominal CT scan revealed: Significant dilatation and distension of the intestinal tract, most pronounced in the lower abdominal region, along with multiple air-fluid levels. Additionally, thickening of the surrounding fascial shadow was observed, indicating intestine obstruction with peritonitis (Fig. 1). A high-density shadow in the pelvic ring, with a diameter of approximately 1.8 cm, suggests the presence of an ectopic IUCD (Figs. 1 and 2). Additionally, there is a small amount of effusion observed in the abdominal cavity and pelvis. Electrocardiogram results indicated arrhythmia, likely associated with atrial fibrillation. Echocardiography revealed enlargement of the left ventricle and right atrium, along with moderate mitral regurgitation. There was also a minor degree of regurgitation in the aortic and tricuspid valves. Routine blood tests showed an elevated white blood cell count of 17.5 × 10^9/L, with a predominance of neutrophils. And C-reactive protein (CRP)was 129.85 mg/L, which was higher than that of limit of normal (5 mg/L). These results indicated that there was serious inflammation in the body. The patient has a history of hypertension, coronary heart disease, heart failure, atrial fibrillation, cerebral infarction treated with interventional therapy, and long-term anticoagulant use. No history of abortion or cesarean section(G₃P₃A₀). A ring IUCD was inserted 47 years ago for contraception, but she hasn’t had any follow-up or removal after menopause (50 years old). No history of other operation.

Fig. 1

Plain abdominal radiograph of this patient showed a metallic ring in the pelvic cavity. The red arrow points to the IUCD

Fig. 2

The abdominal CT scan revealed that the intestine looped through a metal ring, causing obstruction and incarceration. The red triangular arrow points to the obstructed intestine and the IUCD

Due to the patient’s advanced age and poor health, a multidisciplinary consultation confirmed no absolute contraindications to surgery. The patient underwent abdominal exploration (midline incision), revealing swelling and distention in the intestine. A long segment of the intestine, 30 cm from the ileocecal junction, was looped and constricted by a metallic IUCD (Fig. 3). The bowel exhibited a dark, inelastic appearance, accompanied by pronounced edema of the mesentery and the presence of bloody exudate within the pelvic cavity. Due to the necrotic state of the bowel, a resection of the necrotic segment was undertaken, followed by a one-stage end-to-end intestinal anastomosis subsequent to the removal of the IUCD. Histopathological examination post-surgery revealed congestion, hemorrhage, edema, and infiltration of acute and chronic inflammatory cells within the intestinal wall and mucosa, along with chronic mucositis at both sides of the resection margin. By the ninth postoperative day, the patient had recuperated sufficiently to be discharged from the hospital. During 36 months’ follow-up, the patient did not happen any other complication. And she was satisfied with this operation.

Fig. 3

A) The intestine obstructed by the IUCD was observed during surgery; B) the removal of intestine and IUCD. The red triangular arrow points to the IUCD during surgery and post-surgery

Discussion

IUCD ectopic cases are classified by insertion depth into the myometrium: partial (partially inserted), complete (fully inserted), and extrauterine (penetrating through the myometrium). The incidence is 0.3‰-2.6‰[3], with most cases being partial or complete, while full penetration into the abdominal cavity is very rare. Approximately 85% of patients with ectopic IUCDs exhibit no discernible clinical symptoms. However, 15% of these patients experience severe complications [4]. Of all, intestinal obstruction is one of the most serious complications. For example, I Bhatti et al. reported a case with large bowel obstruction due to actinomycosis infection caused by the IUCD [5]. And actinomycosis infection caused by the IUCD can also resulted in ureteral, sigmoid obstruction, and colonic obstruction [6, 7]. Other than actinomycosis, B Rudensky et al. repeoted a cses with pneumococcal intra-abdominal infection caused by IUCD, which resulted in the small-bowel obstruction [8]. On the other hand, internal hernia caused by IUCD is also an important cause of intestinal obstruction. And terminal ileum obstruction [9, 10], small intestinal obstruction [11,12,13,14], which caused by IUCD were reported by different doctors.

The primary factors of IUCD perforation can be summarized as follow: rough operation during insertion, inaccurate placement, excessive depth of insertion, and mismatch between the IUCD size and uterine dimensions [15, 16]. And the median occurrence time of these complications was about 17 months [17]. However, the IUCD in this particular case had been retained for 47 years. Similarly, Jie X. Xu et. also reported a case with the IUCD was placed nearly 50 years. And the IUCD was considered to be fallen out during micturition. However, in fact, the IUCD has transmigrated to the abdominal cavity, and resulted in the small bowel obstruction and ischaemia [18]. Therefore, in our opinion, the prolonged retention period maybe the predominant cause of the patient’s ectopic IUCD in this case.

However, due to the case with extended retention of the IUCD is rare. Therefore, the mechanism for the IUCD penetrating the uterus is unclear. Based on our experience, we speculate that the following factors may cause the IUCD to penetrate the uterus and cause intestinal obstruction in this case: (1) Prolonged use of an IUCD beyond its designated service life results in surface degradation and structural compromise, thereby enhancing its stimulatory effect on the endometrium and potentially leading to ectopic displacement of the IUCD. (2) In postmenopausal patients, the absence of cyclical endometrial changes allows the IUCD to persistently irritate the endometrium as a foreign body, ultimately causing endometrial necrosis and facilitating the penetration of the IUCD into the myometrium; (3) Following menopause, there is a reduction in the secretion of estrogen and progesterone in the patient’s body, leading to decreased uterine elasticity. Consequently, the pressure within the uterine cavity significantly increases during uterine contractions, potentially resulting in the displacement of the IUCD; (4) In this case, the IUCD was ring shape, which is more difficult in the process of insertion than that of t-shaped IUCD. (5) Additionally, the patient’s IUCD, which was ring-shaped, became ectopic to the free abdominal cavity. During episodes of bowel peristalsis, the bowel passed through the IUCD, leading to incarceration and ultimately resulting in strangulated intestinal obstruction. Of course, all of these need further studies to explore and verify.

Conclusion

The location of abdominal pain may not be consistent with the location of intestinal obstruction caused by IUCD. In this case, the first symptom was upper abdominal pain rather than the commonly low abdominal pain. In our opinion, this may be related to the foreign body in the abdomen (IUCD), which stimulate the visceral nerves and cause referred pain. This greatly misled the doctor’s judgment. Due to the atypical symptoms, the doctor mainly considered the possible diagnosis, including gastric ulcer, duodenal ulcer, cholecystitis, cholelithiasis, acute pancreatitis, intestinal obstruction and so on. Therefore, only an upper-abdominal CT scan was conducted. However, no obvious signs were found at this phase. And conversative treatments were given to the patient. This is the main reason for the delayed treatment. If the IUCD was considered at the beginning, and the operation for moving the IUCD, strangulated intestinal obstruction may not happen and intestinal resection will be avoided.

On the other hand, it is imperative for the regular evaluations and removal on time of IUCD. For this case, the patient hasn’t had any follow-up or removal for IUCD after menopause. It was because of her neglect that the IUCD eventually penetrated the uterus, causing strangulation and intestinal obstruction. This is an issue that is easy to overlook. Before menopause, the IUCD was still work for contraception. Therefore, people will assess the device’s position, depth, and potential dislodgement or ectopic migration to other organs regularly to make sure the IUCD could work for her. However, after menopause, the function of the IUCD was not necessary. People no longer pay attention to it, which eventually lead to complications.