Successful Endoscopic Management of Subacute Intestinal Obstruction Presenting 3 Years After Lodgement of a Coin in the Duodenal Cap

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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

References

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• 2 Stack L B, Munter D W.. Foreign bodies in the gastrointestinal tract.  Emerg Med Clin N Am. 1996;  14 493-521
• 3 Tibbitts G M, Sorrell R J.. Duodenal obstruction from a gastric feeding tube.  N Engl J Med. 1999;  340 970-971
• 4 Adams D B.. Endoscopic removal of entrapped coins from an intraluminal duodenal diverticulum 20 years after ingestion.  Gastrointest Endosc. 1986;  32 415-416