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Previous Volume 350:839 February 19, 2004 Number 8 Next

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To the Editor: The medical mystery in the January 1 issue¹ involved a 62-year-old man who had a history of psychosis and who presented with an ileus. An abdominal radiograph revealed a ptotic gastric fundus filled with a very large, radiopaque density (Figure 1A). At laparotomy, the distended stomach was found to contain 5.5 kg of coins, necklaces, and needles (Figure 1B). A partial gastrectomy with Braun's anastomosis was performed because of pressure necrosis. Postoperative complications included septic shock and multiple-organ failure, which resulted in the patient's death on the 12th postoperative day.

View larger version (40K): [in this window] [in a new window]   Figure 1. An Abdominal Radiograph Showing a Ptotic Gastric Fundus Filled with a Very Large, Radiopaque Density (Panel A, Arrows), Identified as a Collection of Coins, Necklaces, and Needles at Laparotomy (Panel B).

 
Close to 90 percent of ingested foreign bodies pass spontaneously, but 10 to 20 percent require endoscopic removal. Removal through laparoscopy or laparotomy is needed in 1 percent of cases. Large or sharp foreign bodies, as in this patient, may obstruct or perforate the stomach or digestive tract and cause death.

Bruno François, M.D.
Association des Réanimateurs
87000 Limoges, France

Olivier Brenet, M.D.
Association des Réanimateurs
49300 Cholet, France

Editor's note: We received 666 responses to this medical mystery — 51 percent from physicians in practice, 27 percent from physicians in training, 10 percent from medical students, and 12 percent from other readers. Responses were received from 73 countries. Eighty-eight percent of respondents gave explanations that were consistent with pica (from the Latin word for magpie, a bird known for eating whatever it comes across). Twenty-three percent correctly identified needles or pins, and 8 percent correctly identified coins. Other explanations included infection (ascariasis), cancer (gastric and transitional-cell carcinomas), endocrine and metabolic illnesses (hypothyroidism, hyperparathyroidism, and porphyria), ingestion of heavy metals (bismuth, mercury, and lead), and bladder disorders (calculi and foreign bodies in the urethral bladder). We received many insightful comments, as well as some that were humorous, including the following: "This man would not pass through airport security"; "Normally you hear about a treasure chest, but this is truly a treasure abdomen"; and "Don't let him in the MRI suite." This case serves as a reminder of important factors that should be considered in the care of patients who are mentally impaired. We encourage all readers to participate in future medical mysteries and to share their insights.

References

1. François B, Brenet O. A medical mystery. N Engl J Med 2004;350:59-59. [Free Full Text]

PDF PDA Full Text Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear Related Article by François, B. PubMed Citation