Date Published: October 24, 2017
Publisher: John Wiley and Sons Inc.
Author(s): Kosuke Sekiya, Shusuke Mori, Yasuhiro Otomo.
Pica is common among patients with psychiatric disorders, but only a few cases regarding coin pica have been reported. A 51‐year‐old man with depression complaining of fatigue was found to have numerous coins in the esophagus and the stomach on X‐rays. He had a peritoneal sign and underwent an emergency laparotomy.
The surgical findings showed perforation on the anterior wall of the gastric body and coins in the stomach, which were removed manually, followed by an omental patch. Residual coins in the esophagus were removed by endoscopy. The coins totaled 1,894, weighing 8,076 grams. The patient was then diagnosed as schizophrenic. He was asymptomatic for metal toxicity and was finally transferred to a psychiatric hospital.
This pica case is the first to show coin pica can lead to gastric perforation, and also reports the largest amounts of coins ingested by a person to date.
Pica is common among patients with psychiatric disorders.1 Although there are various kinds of objects or materials for ingestion in pica cases, reports regarding ingestion of a large number of coins are rarely seen.2, 3, 4, 5, 6, 7 Coin ingestion, regardless of incidentally or accidentally swallowed, is also a common disease occasionally seen in emergency departments; however, these cases are usually marked by small numbers of coins and, therefore, few symptoms are reported, if any. Nonetheless, there are cases in which patients confess to purposely ingesting coins, leading to complications such as narrowing of the gastrointestinal tract or lumen obstruction. Ingesting a large number of coins can only be deemed intentional, and hence, it is usually related to a psychiatric disorder. Pica sometimes causes gastrointestinal tract perforation.8 Foreign bodies such as batteries, sharp objects, and metal materials are the main cause of perforation seen in pica patients. Ingestion of substantial amounts of any foreign body may also lead to perforation. Coin pica has rarely been reported. We herein report this unique case of pica leading to gastric perforation due to ingestion of the largest number of coins ever recorded.
A non‐medicated 51‐year‐old man with a 30‐year history of depression presented to a local hospital complaining of fatigue and loss of appetite. The initial vital signs were: Glasgow Coma Scale 15 (E4V5M6); blood pressure, 139/81 mmHg; heart rate, 114 b.p.m.; respiratory rate, 31 breaths/min; body temperature, 37.2°C; and SpO2, 98%. Physical examination revealed that his abdomen was hard and tender on the left flank, showing signs of peritoneal irritation. The blood test revealed leukocytosis, iron deficiency anemia, thrombocytosis, hypoalbuminemia, hyponatremia, and high C‐reactive protein, but did not show liver or kidney dysfunction (Table 1). Plain chest and abdominal X‐rays showed numerous round‐shaped radiopaque foreign bodies suggestive of coins (Fig. 1A). The patient was diagnosed with coin pica complicated with gastrointestinal tract perforation and he was transferred to the hospital for surgical treatment. On the same day, an emergency laparotomy was performed. Following celiotomy, a hole approximately 5 mm in size was observed on the anterior wall and greater curvature side of the stomach, from which coins were identified. The stomach was remarkably distended with a large number of coins. No coins spilled out from the stomach to the abdominal cavity. The hole seemed to be eroded by the pressure of heavy solid materials. In order to remove the coins, an incision of approximately 5 cm was made on the greater curvature of the stomach separately from the hole that was first observed. After coins in the stomach were removed by hand, the incision was closed primarily. The hole and surrounding tissue seemed structurally weak, presumably due to erosive changes, and, therefore, was closed by a single stitch with the same suture material and an omental patch was applied to the site for reinforcement.
Pica is characterized by the persistent eating of non‐nutritive substances, and is mainly seen in psychiatric patients, children, young adolescents, and pregnant women.1, 9 Lethal complications of pica include intestinal obstruction and perforation with peritonitis.8 Other findings at autopsy may include airway obstruction and heavy metal poisoning.9 Presenting symptoms and signs of such complications may be subtle or masked given the nature of underlying conditions. Therefore a careful evaluation of the medical histories of individuals with pica is necessary to provide pertinent details of associated medical and psychiatric conditions.1, 9 Manifestation of coin pica is diverse, and therefore, its precise diagnosis is sometimes difficult or missed unless the patient admits to swallowing foreign bodies or it is revealed in imaging procedures.10
Pica is common among patients with psychiatric disorders. A few cases regarding coin pica have been reported. However, ours is the first case report complicated by gastric perforation and documents the highest number of ingested coins ever reported.
Informed consent: Written informed consent was properly obtained from the patient in accordance with the guideline of the ethical committee of Tokyo Medical and Dental University.