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During a routine postmortem evisceration, a segment of jejunum of approximately 20 cm was noted to be doubled back upon itself, with fibrous adhesions joining the two halves of the loop creating a “U” shape. The segment of jejunum was opened along the antimesenteric border, and a bile encrusted foreign body was seen to be attached by a free bridge of mucosa where the bowel doubled back upon itself. The object was removed without damaging the mucosal bridge; removal of the encrusted bile showed the foreign object to be a plastic bread bag clip. There was no date on the clip. The bridge of free mucosa passed through the space behind the tooth-like pincers (fig 1). The amount of bile encrustation and the remarkable growth of a mucosal bridge through the clip suggest that it had been present in this particular segment of jejunum for a considerable time. Its presence was unrelated to the cause of death, which was given as coronary artery atherosclerosis, and there was no evidence to suggest that the presence of the bread bag clip had caused problems during life.
The segment of jejunum removed was sliced across, the cut running parallel to the plicae circulares, to cut the mucosal bridge longitudinally. Sections were submitted for histopathological examination. A haematoxylin and eosin stain and an actin immunocytochemistry stain, to highlight muscle, were studied (fig 2). Although there was considerable postmortem autolysis, it was evident that the bread bag clip had been held within a mucosal lined eyelet. The actin stain showed the muscularis propria curving to run below the base of the eyelet; there was no muscularis propria running over the bridge of tissue that retained the clip. The muscularis mucosae similarly did not run in continuity across the top of the eyelet; the eyelet was within the lamina propria and the muscularis mucosae passes around and deep to it. There was a small amount of muscle within the tissue bridge itself but this did not appear to run in continuity across the top of the tissue bridge.
The mechanism of formation of this loop is difficult to determine. The bread bag clip has sharp tooth-like pincers, and would be expected to cause crushing and necrosis of the bowel wall if attachment occurred. Re-epithelialisation of the bowel wall is recognised to take place after crush injury; this phenomenon has been exploited in the past in double barrelled colostomy formation and closure in the Paul-Mikulicz surgical procedure (now obsolete).1–3 The patterns of the musculares propria and mucosae shown by actin immunocytochemistry suggest that the clip has “caught up” the small bowel wall in two places, bringing the “mucosal crest” of each into apposition, with apparent mucosal fusion to form a bridge.
Review of the literature has identified six previous reports of medical problems arising from the accidental ingestion of bread bag clips.4–8 Problems arising included gastrointestinal bleeding, small bowel obstruction, and intestinal perforation. Complications may arise long after ingestion,4,5,7 and there may be no recall of the ingestion.6,8 Although bread bags are now secured with plastic sticky tape, bread bag clips may still be encountered and the potential for late symptomatic presentation in relation to a retained bread bag clip remains.