Rare cause of abdominal pain in a healthy woman.

To the Editor: A 30-year-old female was admitted to the Emergency Department because of left abdominal, dull, ill-defined pain for 2 days. She did not have any prior history of medical or psychiatric illnesses. Two days before this admission, she had gradually experienced uncomfortable pain over the chest and upper back, which became worse when lying down. On the morning of presentation, abdominal pain occurred. The pain was conspicuous and persisted over the left abdomen. Before onset of chest discomfort, the patient had eaten toast with tuna paste. There were no associated fevers, chills, or tarry stool.

Physical examination revealed a nondistended abdomen with hypoactive bowel sounds, but was markedly tender to palpation in the left abdominal region just a little higher than the umbilicus. There was no flank-knocking pain.

The hemogram was as follows: WBC, 8900/uL with 51.4% neutrophils and 41.4% lymphocytes; hemoglobin, 13.7 g/dL; and platelets, 199,000/mL. Urinalysis was normal, and blood chemistries, including renal, liver, and pancreas profiles, were in the normal range. Abdominal plain x-ray showed a foreign body over the left abdominal area without pneumoperitoneum. After consulting for an emergency upper gastrointestinal tract panendoscopy, a metal foreign body was found in the anterior antrum and was easily removed. She was discharged 2 days later without any complications.

The incidence of foreign body swallowing is higher in children than in adults. (1) In adults, foreign object ingestion occurs more commonly in those without teeth or with psychiatric disorders, cerebrovascular accident, or mental retardation. Patient history is the most important clue for early diagnosis. In adults, the history often provides all the pertinent information necessary for diagnosis and treatment. (2) Foreign body ingestion in a young, healthy person without any recollection of an accident is very rare. In this case, the foreign body appeared to be unconsciously swallowed with the tuna paste. Typically, a plain x-ray is helpful for identifying the location and morphology of the foreign body. The abdomen should be examined for evidence of peritonitis, which requires surgical intervention. Although the majority of sharp objects that enter the stomach will pass through the remaining gastrointestinal tract without incidence, the risk of complication is as high as 35%. (3) Therefore, endoscopically retrieving the foreign body should be considered in the ER: the endoscopic procedure allows for removal of a foreign body without complications. (4)

We recommend that the history and the x-ray be evaluated carefully to prevent misdiagnosis.

Shih-Chang Hung, MD

Cheng-Ching Pan, MD

Department of Emergency Medicine

Nantou Hospital

Nantou City, Taiwan

Shih-Wei Lai, MD

Department of Family Medicine

China Medical University Hospital

Taichung City, Taiwan

References

1. Hachimi-Idrissi S, Come L, Vandenplas Y. Management of ingested foreign bodies in childhood: our experience and review of the literature. Eur J Emerg Med 1998;5:319-323.

2. Wade R, Gaash Rober A. Barish. Swallowed foreign body. In: Tintinalli JE, Kelen GD, Stapczynski JS (eds). Emergency Medicine: A Comprehensive Study Guide, 6th ed. Chicago, McGraw-Hill, 2004, pp 513-516.

3. Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc 1983;29:208-210.

4. Mosca S, Manes G, Martino R, et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: report on a series of 414 adult patients. Endoscopy 2001;33:692-696.