Foreign objects in the gastrointestinal tract are usually produced by accidental swallowing, but these objects rarely produce symptoms. Although most foreign objects are passed spontaneously, 10~20% of these patients need treatment1), and approximately 1% will require surgery2). Foreign objects greater than 2 cm in diameter or 5 cm in length are at risk for impaction3). Lymphadenopathy, viral hepatitis, foreign body insertion into the gastrointestinal tract, dental caries and pulmonary tuberculosis are known to be the principal nonpsychiatric and nonobstetrical diagnoses of prison inmates4). Foreign object ingestion is often seen in prisoners who are usually attempting to temporarily escape justice5). There have been several reports regarding foreign objects in prisoners6-10). We report here on a series of 33 Korean prisoners who ingested foreign objects and these patients were managed via endoscopy or surgery. This is the first report for foreign objects in Korean prisoners.

We reviewed the medical records and endoscopic findings of 33 prisoners (52 episodes) who were admitted due to ingestion of foreign objects between January 1998 and June 2004 to either Konyang University Hospital or Gyeongsang National University Hospital. We investigated the time interval between foreign object ingestion and the visit to the ER, the locations, kinds and sizes of foreign objects, the methods of foreign object removal, complications of endoscopic management and the combined disorders of the prisoners. All the patients were evaluated within 48 hours of admission or at the initial presentation of foreign object ingestion and these patients were followed until elimination or removal of the foreign objects.

The majority of foreign object ingestions occur in the pediatric population with a peak incidence between six months and six years of age. In adults, true foreign object ingestion more commonly occurs among those patients with psychiatric disorders, mental retardation or impairment caused by alcohol, and those seeking some secondary gain with access to a medical facility11). Among prison inmates, deliberate foreign object ingestion is usually done to obtain an advantage that occurs secondary to the stated or real illness and it is not done with a suicidal intent. The most common secondary gains are temporary release from jail for treatment in a hospital or, in drug addicts, gaining access to narcotic analgesia. In our study, all the patients except one prisoner intentionally ingested foreign objects, and they achieved their secondary gains. Some reports have suggested that deliberate ingestion of foreign objects by prisoners appears to indicate severe psychiatric impairment and it is associated with particularly violent, impulsive behavior10). All the patients with foreign body ingestion should be consulted to a psychiatric physician. Yet in most cases, however, this is not always possible because of the patients' refusal.

In the general population, the most common ingested foreign bodies are coins in children12) and impacted meat or other types of food bolus in adults2). But for prison inmates in foreign countries, the common foreign objects are razor blades, metallic stars, toothbrushes, radio antennae and so on6-10, 13-15).

The common foreign objects in Korean prisoners were wires, ball.tipped pens and their accessories, needles and toothbrushes. Wires can be obtained from the metal protector of electronic fans in the prison or from the workplace. These ingested objects are different from those of other countries because of the different prison environment in Korea. Also, the prisoners ingested unusual things for secondary gains.

The rate of hospitalization for specifically treating foreign body ingestion in the gastrointestinal tract was 23 times greater for male prisoners than for male non.prisoners and 260 times greater for female prisoners than for female non.prisoners4).

Upper gastrointestinal endoscopy was a useful and effective method for making the diagnosis and treatment of foreign objects in prisoners, as well as for the general population in most cases. Grasping forceps were the most commonly used devices for the removal of foreign object. We used various devices for removing the foreign objects ingested by prisoners. Prevention of ingestion may be the best approach for treatment. Rada and James16) reported success with using behavioral modification and refraining from discussing incidents to reduce the frequency of similar actions among prisoners. Some efforts to improve the prison environment may also be necessary.

In summary, the foreign objects in prisoners were a variety of unusual things because of the prison environment and the secondary gains of the prisoners. Upper endoscopy was a useful and effective method for making the diagnosis and treating foreign bodies in the gastrointestinal tract in most cases.