Case Report
A 54-year-old Syrian woman presented to the emergency department with acute onset, diffuse abdominal pain of 1-day duration which was preceded by 3-weeks of constipation and recurrent postprandial vomiting. She had unexplained weight loss of 47 pounds in the past 6 months. Past medical history was significant for posttraumatic stress disorder, severe depression, and schizoaffective disorder. She lived with her mother and denied use of alcohol, tobacco, or illicit drugs. Her father died of metastatic melanoma and her mother and several maternal uncles were diagnosed with colon polyps and colon cancer. She had worked as a pediatrician before the onset of her psychiatric illness. She had followed up with her family practitioner and psychiatrist for the unexplained weight loss and did not respond to changes in her psychiatric medications. She declined colonoscopy despite several family members with colon polyps and cancer. Laboratory studies revealed: hemoglobin of 11.5 g/mL and a white blood cell count of 11,600 cells/mm3 (85% neutrophils). Liver chemistries were normal. On physical exam, she was non-conversant with diffuse abdominal tenderness, voluntary guarding, and rebound tenderness. A computed tomography of the abdomen and pelvis was performed which showed multiple densities in the stomach and small intestine with a large metallic-appearing body measuring 10x29 centimeters in the pelvis (unfortunately unavailable). The patient underwent urgent exploratory laparotomy with removal of over seventy foreign bodies from the stomach and transverse colon weighing over 5 pounds. Thirty teaspoon handles and other bizarre foreign bodies (laundry clips, rubber seals, coins, nails, necklace, earrings, chandelier crystals, and iPhone cable) were recovered (Figure 1). She developed further complications after the surgery and required intensive care unit admission. Her family elected to proceed with comfort care. The patient denied swallowing these objects, and no family members had witnessed these ingestions. The patient’s behavior of breaking teaspoons to swallow handles represents a form of pica called acuphagia (eating sharp metallic objects).
There are a few cases reported of severe acuphagia associated with impulse control disorders. Mbanaso A., et al. reported a 22-yearold Nigerian man who ingested 497 metallic objects [1]. In our case, the weight loss and postprandial vomiting can be explained by the large foreign body burden in the gut. Although endoscopic removal of foreign bodies in the stomach is the procedure of choice; sharp, foreign objects are at high-risk for causing complications such as perforation and thus need surgical exploration [2]. Care providers should think out of the box when treating patients with different cultures since making the diagnosis of some conditions in a timely manner is critical.
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