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Making Heads or Tails of an Unexpected Colonoscopy Finding

Magee, Jared DO, MPH1; Hall, Noah MD1; Tritsch, Adam MD1

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doi: 10.14309/crj.0000000000000328
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CASE REPORT

An asymptomatic 72-year-old man underwent surveillance colonoscopy for a medical history of a small adenomatous polyp. Intubation of the cecum revealed a metallic foreign body impacted in the appendiceal orifice. Closer inspection revealed an American penny (diameter 19.05 mm, thickness 1.52 mm) (Figure 1). The coin was dislodged with cold forceps, revealing a second American penny underneath (Figure 2). Both coins were removed on single pass with a Roth net after dislodgement. Consideration was given to the retrieval of coins with grasping of cold forceps, but we believed it would be difficult to maintain the grasp through complete removal. In our literature review, there was no direction in the management of coin ingestion in adult patients.

Figure 1.
Figure 1.:
Intubation of the cecum revealed an American penny impacted in the appendiceal orifice.
Figure 2.
Figure 2.:
After dislodging the first penny, a second American penny was revealed.

National and international data collected on pediatric populations show that once the coins have passed the distal esophagus, spontaneous progression is almost certain.1,2 However, case reports have demonstrated that foreign bodies can cause appendicitis because of an inability to re-enter the colon once lodged in the lumen of the appendix.3 Although this patient was asymptomatic at that time, we believed that they could be safely removed in the hope of preventing an episode of appendicitis. Given the risk, albeit small, of impaction leading to appendicitis, both pennies were removed distally.

On questioning after the procedure, the patient was initially confused regarding the origin of the coins. It was determined that they could not have been the product of childhood ingestion because one of the coins bore a mint year of 1981 and they were not present during previous colonoscopies or abdominal imaging. On further reflection, the patient recalled that he often kept medications in his pocket and hypothesized that he might have inadvertently ingested the pennies, mistaking them for pills. We did not pursue additional imaging to rule out additional coin lodgment after his colonoscopy because of his denial of habitually swallowing foreign objects and his asymptomatic presentation.

DISCLOSURES

Author contributions: J. Magee wrote the manuscript and is the article guarantor. N. Hall wrote the manuscript. A. Tritsch edited the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

REFERENCES

1. Singh N, Chong J, Ho J, et al. Predictive factors associated with spontaneous passage of coins: A ten-year analysis of paediatric coin ingestion in Australia. Int J Pediatr Otorhinolaryngol. 2018;113:266–71.
2. Conners GP, Cobaugh DJ, Feinberg R, Lucanie R, Caraccio T, Stork CM. Home observation for asymptomatic coin ingestion: Acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group. Acad Emerg Med. 1999;6:213–7.
3. Sama CB, Aminde LN, Njim TN, Angwafo FF III. Foreign body in the appendix presenting as acute appendicitis: A case report. J Med Case Rep. 2016;10(1):129.
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