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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e3182500414
Image of the Month

Unconventional Firepower: An Unexpected Source of Lead Poisoning

Terry, Annie; Muir, Linda; Eroglu, Yasemen; Byrne, William; Zhang, Zili

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Division of Pediatric Gastroenterology, Oregon Health and Science University, Portland, OR.

Address correspondence and reprint requests to Zili Zhang, MD, PhD, Oregon Health and Science University, Mail code: CDRCP, 707 SW Gaines St, Portland, OR 97239 (e-mail:

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

A 15-year-old boy with developmental delay ate poorly and complained of stomachache for 3 weeks. One day before admission, he vomited a broken fork handle. Subsequent x-ray revealed metallic objects in the stomach. Esophagogastroduodenoscopy found 3 larger caliber bullets in the gastric body, which were removed endoscopically (Fig. 1). Although physical examination was unremarkable, the patient had persistently elevated systolic and diastolic blood pressure. In addition, his hemoglobin decreased from normal level to 6.7 g/dL in the last month. Fecal occult blood test was negative and urinalysis revealed elevated urobilinogen. His blood lead level was 146.7 μg/dL (normal range <10 μg/dL). This patient presented with several cardinal signs of lead intoxication including anemia, abdominal pain, and hypertension (1,2). Thus, chelation therapy was initiated. Bullets often consist of a lead core in a copper jacket, and are likely the primary culprit causing the markedly elevated lead level in this case. Although lead poisoning due to retained bullets is rare, several case reports showed that retained bullets can cause severe lead toxicity (3–5). This case underscores the importance of ruling out lead poisoning in patients ingesting lead-containing foreign bodies.

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1. Hu H. Exposure to metals. Prim Care 2000; 27:983–996.

2. VanArsdale JL, Leiker RD, Kohn M, et al. Lead poisoning from a toy necklace. Pediatrics 2004; 114:1096–1099.

3. Coon T, Miller M, Shirazi F, et al. Lead toxicity in a 14-year-old female with retained bullet fragments. Pediatrics 2006; 117:227–230.

4. Linden MA, Manton WI, Stewart RM, et al. Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg 1982; 195:305–313.

5. Gorospe EC, Gerstenberger SL. Atypical sources of childhood lead poisoning in the United States: a systematic review from 1966-2006. Clin Toxicol (Phila) 2008; 46:728–737.

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