We report a rare case of perforation of the ileum end due to the accidentally swallowed press through package (PTP). A 68-year-old man was seen at the hospital at night because of lower abdominal pain. Inspite of marked tenderness in the lower abdomen and fever, the white blood cell count was 8550/mm³ which was within normal limits. So we chose conservative treatment using antibiotics. On the next day, the white blood cell count was slightly elevated to 9520/mm³, tenderness was intensified, and the Blumberg's sign was noted. Abdominal CT scan revealed free air around the ileum end and mesentry, so we performed an emergency operation. Inflammatory changes around the ileum and cecum were slight and ileo-ceacal resection was carried out. We found PTP in the oral stump of the ileum end. After the operation we detected the perforation due to PTP in the resected ileum end.
We think that some devices in package of drugs would be necessary, because clinical cases of various diseases caused by ingested PTP are increasing year by year.