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Rethinking the watchful waiting approach to the swallowed coin problem
Images in surgery This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to submit items for consideration.
Rethinking the watchful waiting approach to the swallowed coin problem Ruben Gomez, MD, PhD, and Marc D. Basson, MD, PhD, Detroit, Mich
From the Departments of Surgery, John D. Dingell VA Medical Center and The Wayne State University Medical School, Detroit, Mich
A 55-YEAR-OLD MAN with schizophrenia was transferred to our hospital after being resuscitated with 4 units of packed red blood cells after hematemesis. There were no signs of peritonitis, and the hemoglobin level on presentation was 6.7 g/dL. To evaluate the hematemesis, the patient underwent esophagogastroduodenoscopy, demonstrating a large clot occupying and obstructing the gastric outlet (Fig 1, A). Numerous coins were impacted in the clot, and recent bleeding was evident. The abdominal radiograph (Fig 1, B) revealed a large metallic bezoar in the antrum of the stomach consistent with the endoscopy findings. Because of the presence of the large number of coins and the evidence of bleeding, the patient underwent a laparotomy and gastrostomy. Multiple coins were found impacted in a clot filling the distal antrum. Two sharp-edged pennies were seen adjacent to a scooped-out bleeding gastric ulcer at the gastrostomy line. The clots and coins were removed, and the gastric ulcer was resected. The stomach and abdomen were closed. The removed coins and the pathologic section of part of the gastric ulcer are shown in Fig 2, A and B, respectively. Accepted for publication August 17, 2002. Reprint requests: Marc D. Basson, MD, PhD, Department of Surgery, John D. Dingell VA Medical Center, and The Wayne State University Medical School, 4646 John R, Detroit, MI 48201. Surgery 2003;133:698–9. © 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30 + 0 doi:10.1067/msy.2003.14
698 SURGERY
The patient experienced an uneventful postoperative course. DISCUSSION American pennies minted after October 1982 have a core zinc content of 97.6% of volume with a thin copper coating of 2.4% of volume.1 When these coins are exposed in vitro to 0.15 N HCl, simulating postprandial gastric succus, they begin to leach zinc within hours. By 24 hours, they begin to visibly corrode. The zinc forms zinc chloride in solution.1 The corrosion gives the coins a motheaten and scalloped appearance on radiologic and physical examination. In contrast, coins of other denominations are relatively intact (Fig 2, A). The easily absorbed zinc chloride has systemic and local effects on the gastric mucosa. Locally, zinc produces corrosion and ulceration of the mucosa. Fig 2, B shows the denuded mucosa with an inflammatory reaction in the submucosa. The clinical correlates of these findings may include nausea, vomiting, hematemesis, and abdominal cramping.2 In addition, the sharp points and edges of the corroded pennies may physically injure the mucosa. Systemically, zinc has been shown to have adverse effects on multiple organs, including the pancreas, kidney, liver, and hematopoietic system. Indeed, death has been reported from multiple system organ failure.2 Our patient did not have a fatal outcome, perhaps because his coin load was not as large as in the patient previously reported or because we acted quickly to remove the coins from the stomach. Watchful waiting has been the traditional method of treating patients who have ingested
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Surgery Volume 133, Number 6
Fig 2. A, Still photograph of some of the coins removed from the patient’s stomach by gastrostomy. The pennies, in contrast with the coins of the other denominations, show the scalloped edges from the leaching effects of HCl in the stomach. B, Pathologic specimen showing ulcerated gastric mucosa with signs of acute and chronic inflammation and hemorrhage. Fig 1. A, Endoscopic view of coins in the stomach. Also shown are gastric erosions and signs of recent bleeding. B, Portable abdominal radiograph showing radio-opaque densities in the antrum of the stomach consistent with the findings at endoscopy.
tric emptying. Extraction may be performed endoscopically (with airway protection to prevent aspiration) or, if necessary, surgically.
coins that pass into the stomach.3 However, numerous complications may occur after the ingestion of post-1982 pennies. Early extraction of such coins from the stomach may be warranted, especially if the coins present a moth-eaten or scalloped appearance on radiologic examination, ulceration has occurred, or the bezoar appears to impede gas-
1. O’Hara SM, Donnelly LF, Chuang E, Brinner WH, Bisset GS. Gastric retention of zinc-based pennies: radiographic appearance and hazards. Radiology 1999;213:113-7. 2. Bennett DR, Baird CJ, Chan KM. Zinc toxicity following massive coin ingestion. Am J Forensic Med Pathol 1997;18:148-53. 3. American Society for Gastrointestinal Endoscopy. Guidelines for the management of ingested foreign bodies. Gastrointestinal Endosc 1995;42:622-5.
REFERENCES
Rethinking the watchful waiting approach to the swallowed coin problem Ruben Gomez, MD, PhD, and Marc D. Basson, MD, PhD, Detroit, Mich
From the Departments of Surgery, John D. Dingell VA Medical Center and The Wayne State University Medical School, Detroit, Mich
A 55-YEAR-OLD MAN with schizophrenia was transferred to our hospital after being resuscitated with 4 units of packed red blood cells after hematemesis. There were no signs of peritonitis, and the hemoglobin level on presentation was 6.7 g/dL. To evaluate the hematemesis, the patient underwent esophagogastroduodenoscopy, demonstrating a large clot occupying and obstructing the gastric outlet (Fig 1, A). Numerous coins were impacted in the clot, and recent bleeding was evident. The abdominal radiograph (Fig 1, B) revealed a large metallic bezoar in the antrum of the stomach consistent with the endoscopy findings. Because of the presence of the large number of coins and the evidence of bleeding, the patient underwent a laparotomy and gastrostomy. Multiple coins were found impacted in a clot filling the distal antrum. Two sharp-edged pennies were seen adjacent to a scooped-out bleeding gastric ulcer at the gastrostomy line. The clots and coins were removed, and the gastric ulcer was resected. The stomach and abdomen were closed. The removed coins and the pathologic section of part of the gastric ulcer are shown in Fig 2, A and B, respectively. Accepted for publication August 17, 2002. Reprint requests: Marc D. Basson, MD, PhD, Department of Surgery, John D. Dingell VA Medical Center, and The Wayne State University Medical School, 4646 John R, Detroit, MI 48201. Surgery 2003;133:698–9. © 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30 + 0 doi:10.1067/msy.2003.14
698 SURGERY
The patient experienced an uneventful postoperative course. DISCUSSION American pennies minted after October 1982 have a core zinc content of 97.6% of volume with a thin copper coating of 2.4% of volume.1 When these coins are exposed in vitro to 0.15 N HCl, simulating postprandial gastric succus, they begin to leach zinc within hours. By 24 hours, they begin to visibly corrode. The zinc forms zinc chloride in solution.1 The corrosion gives the coins a motheaten and scalloped appearance on radiologic and physical examination. In contrast, coins of other denominations are relatively intact (Fig 2, A). The easily absorbed zinc chloride has systemic and local effects on the gastric mucosa. Locally, zinc produces corrosion and ulceration of the mucosa. Fig 2, B shows the denuded mucosa with an inflammatory reaction in the submucosa. The clinical correlates of these findings may include nausea, vomiting, hematemesis, and abdominal cramping.2 In addition, the sharp points and edges of the corroded pennies may physically injure the mucosa. Systemically, zinc has been shown to have adverse effects on multiple organs, including the pancreas, kidney, liver, and hematopoietic system. Indeed, death has been reported from multiple system organ failure.2 Our patient did not have a fatal outcome, perhaps because his coin load was not as large as in the patient previously reported or because we acted quickly to remove the coins from the stomach. Watchful waiting has been the traditional method of treating patients who have ingested
Gomez and Basson 699
Surgery Volume 133, Number 6
Fig 2. A, Still photograph of some of the coins removed from the patient’s stomach by gastrostomy. The pennies, in contrast with the coins of the other denominations, show the scalloped edges from the leaching effects of HCl in the stomach. B, Pathologic specimen showing ulcerated gastric mucosa with signs of acute and chronic inflammation and hemorrhage. Fig 1. A, Endoscopic view of coins in the stomach. Also shown are gastric erosions and signs of recent bleeding. B, Portable abdominal radiograph showing radio-opaque densities in the antrum of the stomach consistent with the findings at endoscopy.
tric emptying. Extraction may be performed endoscopically (with airway protection to prevent aspiration) or, if necessary, surgically.
coins that pass into the stomach.3 However, numerous complications may occur after the ingestion of post-1982 pennies. Early extraction of such coins from the stomach may be warranted, especially if the coins present a moth-eaten or scalloped appearance on radiologic examination, ulceration has occurred, or the bezoar appears to impede gas-
1. O’Hara SM, Donnelly LF, Chuang E, Brinner WH, Bisset GS. Gastric retention of zinc-based pennies: radiographic appearance and hazards. Radiology 1999;213:113-7. 2. Bennett DR, Baird CJ, Chan KM. Zinc toxicity following massive coin ingestion. Am J Forensic Med Pathol 1997;18:148-53. 3. American Society for Gastrointestinal Endoscopy. Guidelines for the management of ingested foreign bodies. Gastrointestinal Endosc 1995;42:622-5.
REFERENCES