Pediatric ingestion of seven lead bullets successfully treated with outpatient whole bowel irrigation

Over 5000 cases of lead exposure in children under the age of six are reported to US Poison Centers annually. Gut decontamination as whole bowel irrigation (WBI) has been successfully used in the hospital setting to prevent absorption after ingestion of lead-containing foreign bodies. A 14 month old female presented to clinic 1-hr post ingestion of seven lead bullets. Syrup of ipecac was given but no bullets were in the emesis. X-rays confirmed all bullets were in the small bowel. The physician then called the Poison Center (PCC) for recommendations. Referral to a hospital for WBI, blood lead level (BLL), complete blood count, and straining stools to account for all bullets was advised. Five hours post-ingestion the physician stated the parents refused hospital referral and were administering WBI to the child at home without complications. Twenty-four hours post ingestion the child remained stable at home, had passed four bullets, and was still receiving WBI without complications. At 48 hours post-ingestion the child remained asymptomatic, still tolerating WBI and five bullets had passed. Seventy-two hours post-ingestion two bullets were confirmed by X-ray to be in the bowel. The patient remained asymptomatic and was still tolerating WBI. By 96 hours post ingestion seven bullets were recovered and X-ray confirmed no bullets remained. One month post ingestion BLL = 15.5 mg/dL and the child had no signs or symptoms of lead toxicity. In the acidic environment of the stomach, lead can dissolve and be absorbed resulting in potentially serious lead toxicity. WBI has been successfully used in the management of lead exposures in the hospital setting. This case illustrates the successful use of gut decontamination with WBI in the outpatient setting to treat a potentially toxic lead-containing foreign body ingestion. Rather than admitting a child for a lengthy stay for WBI after ingestion of lead-containing foreign objects, compliant parents may administer WBI at home to asymptomatic children. Follow-up with X-rays to ensure the passage of the foreign object and a BLL are also recommended.