ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—STOMACH
Acuphagia Presenting with Vomiting, Abdominal Pain, and Weight Loss
Pica is a psychological disorder defined as the persistent eating on non-nutritive substances. Acuphagia is a form of pica characterized by the consumption of sharp metallic objects. Some of these objects may cause complications such as intestinal obstruction. The diagnosis cold be missed if the patient is not witnessed ingesting these objects. A 54-year-old 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 post-traumatic stress disorder, severe depression, and schizoaffective disorder. She lived with her mother and denied use of alcohol, tobacco, or illicit drugs. She had worked as a pediatrician before the onset of her psychiatric illness. 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, shewas non-conversant with diffuse abdominal tenderness, voluntary guarding, and rebound tenderness.. A computed tomography of the abdomen and pelvis was performed (figure A) and showed multiple densities in the stomach and small intestine with a large metallic-appearing body measuring 10 x 29 centimeters in the pelvis. 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 B). 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-year-old Nigerian man who ingested 497 metallic objects. 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.© The American College of Gastroenterology 2018. All Rights Reserved.