Individuals who ingest coins are usually simply observed, because the majority of coins which pass into the stomach move unimpeded through the gastrointestinal tract [1]
[2]. It is rare for ingested coins which pass through the pylorus to lodge in the small bowel, and even rarer for this not to present acutely but rather several years later. A 52-year-old man presented with a 9-month history of intermittent epigastric pain and profuse vomiting, each bout lasting a few hours. These episodes settled spontaneously, and he was entirely well in between. The patient had accidentally swallowed a coin over 3 years previously which had not obviously passed. Physical examination showed normal findings. An abdominal plain film showed a coin-shaped metallic density in his mid-abdomen. Gastroscopy revealed an Irish 50 pence coin in the duodenal cap (Figure [1]). The coin was firmly adherent to the duodenal mucosa on one of its edges, but appeared to swing about this axis and intermittently occlude the pyloric opening. There was a duodenal diverticulum just proximal to the site of the coin. The coin was dislodged with a snare and retrieved using a basket (Figure [2]). At follow up 3 months later, the patient remained well with no further gastrointestinal symptoms.
There are very few reports of patients ingesting foreign objects and presenting with subacute obstruction at a later date. One describes a patient in a persistent vegetative state who presented with obstruction 6 months after ingestion of the pulp of his feeding catheter [3], and another describes subacute small bowel obstruction in a patient with entrapped coins in an intraluminal duodenal diverticulum 20 years after ingestion [4]. Although rare, duodenal anomalies should be considered in the differential diagnosis of foreign bodies lodged in the duodenum [4]. Our patient had a duodenal diverticulum. Deformity around diverticula may promote lodgement of foreign objects.
Figure 1 Endoscopic image of coin acting like a “ball-valve” at the pylorus. The coin was adherent to the mucosa in the duodenal cap by one of its edges, about which it appeared to swing
Figure 2 The retrieved Irish 50 pence coin was oxidised, and the date was obliterated. It measured about 28 mm in maximum diameter
