Ileal Perforation Caused by the Accidental Ingestion of a Press-Through Package in an Elderly Patient With Dementia: A Case Report.

A woman in her 90s who lived alone and had a history of unspecified dementia and pulmonary tuberculosis presented with a four-day history of lower abdominal pain. Her only regular medication was diazepam, which she dispensed from a press-through package (PTP) and had been cutting individual tablets from the sheet using scissors. Upon admission, she was hypothermic (body temperature 34°C), with otherwise preserved vital signs (blood pressure 131/65 mmHg, heart rate 79 beats/min, SpO₂ 98% on room air). She had no recollection of having swallowed a PTP. Laboratory findings showed a markedly elevated C-reactive protein level of 32.58 mg/dL, severe hypoalbuminemia (albumin 2.4 g/dL), and mild metabolic acidosis (pH 7.300, HCO₃⁻ 17.6 mmol/L) on arterial blood gas analysis. Abdominal computed tomography (CT) revealed a high-density object surrounded by a low-density halo in the ileum approximately 10 cm proximal to the ileocecal valve, along with localized free air and abscess formation in the right lower abdomen, consistent with a PTP-induced ileal perforation. Emergency laparotomy revealed a spindle-shaped ileal perforation, with an intact PTP sheet partially extruding through the defect. An abscess had formed between the abdominal wall and the bowel at the perforation site. Primary repair, omental reinforcement, and peritoneal lavage with drainage were performed without bowel resection or stoma creation. The patient recovered without complications and was discharged on postoperative day 15. This case illustrates two key points: the characteristic CT appearance of a retained PTP can confirm the diagnosis even without an ingestion history, and occult PTP ingestion should be considered in elderly patients with dementia who present with acute abdomen, irrespective of whether an ingestion history can be elicited.