A 36-year-old single unemployed man who was first diagnosed with schizophrenia by a psychiatrist about 12 years ago is described here.\nHe remained in school until the eighth grade, when his abnormal behaviors at school caused him to stop his education. Also, for the same reason, he was fired from his job 2 years ago. He has been smoking cigarettes since 12years ago, and he started to smoke opium 11 years ago.\nHe did not have any evidence of brain damage or any major medical illnesses. He was the second child in a family of 6 with low socio-economic status. His parents were consanguineous and had no physical or mental abnormalities, although one of his younger brothers suffered from mental retardation. During the 12 years of his disease, he has been treated in both outpatient and inpatient settings. Due to exacerbation of his symptoms, he was admitted to a psychiatric ward on 4 occasions, and the course of his illness shows a fluctuating clinical picture. Since his first disease symptoms, he was diagnosed with personality disorder (borderline type), bipolar disorder, and even factitious disorder. His compliance with taking the prescribed medications and attending follow-ups has been very poor.\nDuring the initial phase of his illness, he had prominent positive features, occasional violent outbursts, and delusions of persecution regarding his family and neighbors. All of his hospital admissions were due to psychotic exacerbations, which initially manifested as violent behavior and aggression towards others and then progressed to delusions of persecution, delusions of reference, and both auditory and visual hallucinations. During this phase of his disease, he was diagnosed with schizophrenia. He had a good appetite, but was suffering from early and terminal insomnia. He also had a history of self-mutilation from about ten years ago, but at the time of visit had no suicidal or homicidal thoughts or plans. His initial treatment plan included Valproic acid 200mg tablets TID (600 mg/day) and an Olanzapine tablet 5mg per day. Two years ago, this regimen was changed by his psychiatrist to Haloperidol 5 mg BID (10 mg/day), Biperiden 2 mg/day, Clonazepam 1 mg/day, Citalopram 20mg BID (40 mg/day), and Propranolol 10mg BID (20 mg/day) prescribed as oral medication. During his hospital admissions, he made steady recoveries, but his follow-ups and compliance were poor. All of his laboratory work-ups and brain computed tomography scans (CT scans) were normal and his electroencephalograms (EEG) showed no abnormalities.\nDuring his fourth and last admission, he was brought to the emergency department because of severe abdominal pain. He had abdominal tenderness in his physical examination and his vital signs were stable. His abdominal X-ray revealed the ingestion of a metallic skewer that was broken apart (). After surgical consultation, endoscopic removal of the objects was suggested, but about an hour later the patient became medically unstable and had a board-like abdomen in his examination. After a second evaluation by a surgical team, the patient was diagnosed with intestinal perforation and an emergency exploratory laparotomy with enterotomy was performed. The surgery was without complications, and metallic items were removed from the patient’s abdomen. He had an uneventful postoperative recovery.\nAfter his recovery, at the subsequent psychiatric follow-up visit, he explained his motive for ingesting the metallic skewer and revealed that a demon that had been living inside his body had been controlling him for the previous three months. He insisted that the demon wouldn’t let him tell the psychiatrists about its existence and wanted to control and use his soul to destroy the world. He believed that he could fight and kill the demon by ingesting the metallic skewer.\nTwo weeks after abdominal surgery, the patient attended our psychiatry outpatient clinic twice. He continued to have delusions of persecution and reference; however, he was convinced that because the surgery involved opening his abdomen, the demon had left his body and there was no need to fight with him anymore. Due to close monitoring by his family members, he did not ingest any further non-food items. Also, this close monitoring helped him have better compliance with his psychiatric visits and therapies.
A 47-year-old Iranian woman presented to our hospital with the chief complaint of pain in the abdomen (mostly in the epigastric area) for the previous 2 days, associated with recurrent vomiting, nausea, and anorexia. Her complaints had started 2 hours after the accidental ingestion of a dental prosthesis about 2 days before admission (Fig. ). The patient has a known history of asthma and migraine headache and a history of wearing artificial dentures. At the time of admission, she was conscious and oriented to time, place, and person. Her pulse rate was 90 beats per minute, and her blood pressure was 100/60 mmHg. Her physical examination revealed severe epigastric and mild right upper quadrant abdominal tenderness.\nA radiograph showed no free gas under the right dome of the diaphragm and no air-fluid level (Fig. ). Ultrasonography revealed that there was no free fluid in the peritoneal cavity. Spiral abdominal computed tomography (CT) with oral and intravenous contrast revealed duodenal wall thickness in D2–4, peripheral mesenteric fat edema, hematoma in D1–3, air in the intestinal wall, pneumoretroperitoneum, laceration in D1–2 and a part of D3, and microperforations in D2–3. Because of the hematoma, narrowing in the primary and middle parts of the duodenum was seen (Figs. and ).\nVideo endoscopic findings were an old healed linear ulcer scar in the bulb of the duodenum, and also a swallowed lodged denture was seen in D2–3 after a papilla, which left a laceration behind. An attempt to capture the foreign body was not possible because of difficulty in the procedure and the chance of induced laceration, so a gastroenterologist recommended surgical evacuation of the denture. Laboratory investigation results are shown in Table .\nAfter preparation of the operation site, a midline laparotomy was performed. The stomach and small bowel were examined carefully for any perforation, but no pathology was revealed; however, a foreign body was palpable between the second and the third portions of the duodenum inside the lumen, so duodenal kocherization was performed to explore the duodenum for any perforations. There was no gross perforation in the duodenal wall, so the foreign body was pushed through the lumen to pass back to the stomach from the pylorus. A gastrostomy was performed, and the foreign body was removed and identified as an artificial denture (Fig. ). Then the stomach was repaired in two layers. Washing with normal saline was done, and an abdominal drain was placed at the duodenal site of kocherization. The patient recovered well postoperatively and was discharged on the ninth day of her total hospitalization in good condition.