A penny for your thoughts: Small bowel obstruction secondary to coin ingestion

doi:10.1016/j.jemermed.2004.03.013

The Journal of Emergency Medicine

Volume 27, Issue 3, October 2004, Pages 249-252

https://doi.org/10.1016/j.jemermed.2004.03.013 Get rights and content

Abstract

We report a case of small bowel obstruction secondary to coin ingestion. A 22-year-oldwoman presented to the Emergency Department (ED) with a 3-week history of abdominal pain. Upon initial history the patient denied any foreign body ingestion. Only after computed tomography (CT) scanning of the abdomen and pelvis did the patient admit to deliberate ingestion of a single United States penny coin. During surgical evaluation it was found that the coin had lodged near the ileocecal valve and an inflammatory mass had formed around the intraluminal coin, causing a 10 × 7 cm fibrous tumor to completely obstruct the small bowel. It is thought that oxidation of the coin, with subsequent exposure of its high zinc content, instigated the inflammatory cascade.

Introduction

Small bowel obstruction is an important cause of abdominal pain in Emergency Department (ED) patients. Common causes include postoperative intra-abdominal adhesions, hernias, and occasionally neoplasms. Less commonly, foreign body ingestions have been reported as the etiology of obstruction. In recent years, there have been reports of small bowel obstruction due to organic material such as fruit pits and crustacean shells, and inorganic material such as dental molds, vascular grafts and postoperative hardware (1, 2, 3, 4, 5, 6).

Section snippets

Case report

The patient was a 22-year-old woman presenting with a 3-week history of worsening abdominal pain. She described the pain as sharp, intermittent, located in the right lower quadrant with no alleviating or exacerbating factors, and associated with intermittent vomiting. During this time, she described a 10-pound weight loss. She had normal bowel movements and flatus, with the last bowel movement being 6 h before arrival. Approximately 1 week before presentation she was seen in another hospital ED

Hospital course

At operation, the terminal ileum was found to be grossly fibrotic with a bowel wall thickness of 3.0 cm. There was a large stricture at the ileocecal valve where a partial perforation due to a rusted copper penny was found. Resection of 25 cm of the distal ileum was done. There was no indication of prior ileocecal valve stricture (see Figure 2).

Discussion

Small bowel obstruction is a common problem encountered in the evaluation of ED patients who present with significant abdominal pain, nausea and vomiting. As many as 20% of patients admitted to a surgical service for acute abdominal pain are found to have bowel obstruction (7). Obstruction may be mechanical or due to adynamic ileus. Approximately 50% of mechanical obstructions are due to postoperative intra-abdominal adhesions, with hernias, neoplasms, and inflammatory processes or strictures

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Cited by (8)

Predictive factors associated with spontaneous passage of coins: A ten-year analysis of paediatric coin ingestion in Australia
2018, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Coins are the most commonly ingested foreign body among paediatric populations [1,2]. Although most ingested coins are either passed spontaneously or retrieved with medical intervention, without serious consequence, there is potential for serious morbidity and mortality to occur if the coins remain in the gastrointestinal tract [3–7]. Complications can include stricture formation, oesophageal perforation, tracheo-oesophageal fistula and aorto-oesophageal fistula [8].
Coins are the commonest foreign body ingested in paediatric populations. Although most ingested coins are either spontaneously passed or retrieved with medical intervention without serious consequence, there is potential for serious morbidity and mortality related to paediatric coin ingestion. We performed a 10-year retrospective review of Australian denomination coin ingestion at a tertiary paediatric hospital in Sydney, Australia. We attempted to determine whether a relationship exists between coin size, patient age, coin ingestion and spontaneous passage.
Hospital records of all children presenting in a 10-year period to a paediatric tertiary care centre for coin ingestion were reviewed. Demographic information, coin denomination, previous history, symptoms, investigations, management, outcome and complications were recorded.
241 cases were identified. The majority (55%) of cases occurred in children ≤3 years of age (range 7 months–11 years, mean 3.39 years). The most common location where coins were identified was in the proximal third of the oesophagus or at the cricopharyngeus (65%). Spontaneous passage occurred in 84 cases (34.9%) while 167 cases (69.3%) required intervention. Children ≤3 years were more likely to ingest small coins (<22 mm) (OR: 2.44; 1.39–4.17) and children >3 years were more likely to ingest larger coins (22–26 mm) (OR: 2.17; 1.39–4.35).
Coin size, coin weight and age of the child appear to be predictors for both likelihood of ingestion and spontaneous passage in paediatric coin ingestion cases. A child with minimal symptoms, witnessed ingestion and radiographic identification of the coin in the lower oesophagus or more distal can often be safety observed for up to 24 h in anticipation of spontaneous passage.
A systematic review of paediatric foreign body ingestion: Presentation, complications, and management
2013, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
In fewer than 10% of cases, foreign bodies may impact within the intestines [15]. Foreign body impaction may result in complications such as mucosal abrasions within the gastrointestinal tract, bleeding, gastric outlet obstruction, oesophageal or gastrointestinal perforation and secondary mediastinitis, peritonitis, abscess or fistula formation [16–19]. Therefore, impaction is generally a strong indication for foreign body removal.
Foreign body ingestion is a common problem among paediatric populations. A variety of foreign bodies are ingested, some of which are particularly harmful and life threatening such as button batteries, magnets and bones. Common household items such as small toys, marbles, batteries and erasers are often ingested. The aim of this systematic review is to study the problem of foreign body ingestion among paediatric populations in terms of commonly ingested objects, and attempt to identify the link between location of impaction, associated symptoms, complications, spontaneous passage, methods and timing of removal.
A literature search of multiple databases including PubMed, Embase, Current Contents Connect and Medline were conducted for studies on foreign body ingestions. Based on strict inclusion and exclusion criteria, 17 studies were selected. A qualitative review of these studies was then performed to identify commonly ingested foreign bodies, symptoms, signs and complications of foreign body ingestion, rates of spontaneous passage and methods of retrieval of the ingested objects.
Coins are the most commonly ingested foreign body. A variety of gastrointestinal symptoms such vomiting and drooling as well as respiratory symptoms such as coughing and stridor are associated with foreign body ingestion. The oesophagus, in particular the upper third, is the common site of foreign body obstruction. Objects in the stomach and intestine were spontaneously passed more frequently than at any other sites in the gastrointestinal system. Complications such as bowel perforations, infection and death are more commonly associated with ingestion of objects such as batteries and sharp objects such as bones and needles. Ingested objects are most commonly removed by endoscopic means.
Foreign body ingestion is a common paediatric problem. Batteries and sharp objects should be removed immediately to avoid complications while others can be observed for spontaneous passage. Endoscopy has a high success rate in removing ingested foreign bodies.
Numismedica: Health problems caused by coins
2009, American Journal of the Medical Sciences
Citation Excerpt :
A schizophrenic man who ingested multiple coins developed a sigmoid volvulus due to a coin bezoar.11 Swallowed coins can vary from being asymptomatic to producing symptoms such as failure to drink, pain, and obstruction.9,12–16 One review of 592 cases of esophageal coins found 24% to be asymptomatic.13
Coins occasionally cause health problems. These have a wide range of presentations and can affect multiple organ systems. This article presents a review of the medical literature addressing health problems caused by coins. These problems can be categorized as follows: (1) respiratory manifestations of ingested coins, (2) gastrointestinal manifestations of swallowed coins, (3) systemic effects of swallowed coins, (4) clinical management of swallowed coins, (5) allergic manifestations of coin exposure, and (6) miscellaneous health issues related to swallowed coins.
Massive Penny Ingestion: The Loot with Local and Systemic Effects
2008, Journal of Emergency Medicine
Citation Excerpt :
This may give a false impression of the coins being in the colon, just as in our case (6,7). Coins may become impacted at sites of gastrointestinal tract narrowing like the proximal or distal esophagus and terminal ileum, leading to perforation or the development of an inflammatory mass, leading to bowel obstruction (6,12–14). After absorption, zinc concentrates in the liver, pancreas, and kidney as well as erythrocytes, hippocampus, cerebellum, prostate and bone, and is excreted primarily via bile and pancreatic juice into the feces (5,19).
A 57-year-old schizophrenic woman presented with lethargy, nausea, vomiting, and anorexia after coin ingestion. She was found to have multiple organ dysfunction manifested as hepatitis, pancreatitis, severe anemia with markedly depressed bone marrow response, extravascular hemolysis, and acute renal failure. Prolonged exposure to zinc from massive coin ingestion was responsible. Zinc poisoning is an unusual consequence of coin ingestion in the adult human literature. A detailed discussion on zinc poisoning, as well as the pitfalls in radiological diagnosis of massive coin ingestion, is presented.
Keeping an eye out for bowel obstruction
2006, Pediatric Emergency Care
Rare case of foreign body in the digestive tract
2006, Proktologia

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Clinical CommunicationsA penny for your thoughts: Small bowel obstruction secondary to coin ingestion

Abstract

Introduction

Section snippets

Case report

Hospital course

Discussion

Am J Surg

Surgery

Ann Emerg Med

Gastrointest Endosc

Am J Emerg Med

Small bowel obstruction due to pickled Japanese apricot: CT findings

J Comput Assist Tomogr

Small bowel obstruction caused by snail's shell: radiographic and CT findings

J Comput Assist Tomogr

Clinical Communications
A penny for your thoughts: Small bowel obstruction secondary to coin ingestion