Tennessee Medicine E-Journal
Volume 1 | Issue 4
Article 3
November 2015
$3,000 for $1.05: Short Changed?
Meena Sunil
Internal Medicine/Infectious Disease, Lubbos Medical Clinic & Byrd Regional Hospital, Leesville, Louisiana,
[email protected]
Gary Malakoff
University of Tennessee College of Medicine, Chattanooga, [email protected]
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Recommended Citation
Sunil, Meena and Malakoff, Gary (2015) "$3,000 for $1.05: Short Changed?," Tennessee Medicine E-Journal: Vol. 1: Iss. 4, Article 3.
Available at: http://ejournal.tnmed.org/home/vol1/iss4/3
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$3,000 for $1.05: Short Changed?
By Meena Sunil, MD, and Gary Malakoff, MD, FACP
ABSTRACT
Ingestion of coins or other foreign objects is a common occurrence, more so in children than adults. This
may be accidental or intentional. Multiple symptoms and signs have been attributed to foreign body
ingestion. We report an unusual case of an incidental finding of ingested coins in the stomach of an
adult. The patient underwent endoscopic retrieval of the coins as per current guidelines. We present a
brief discussion of unusual presentations of ingested coins in adults, as well as a review of the literature
on management strategies for foreign body ingestions.
INTRODUCTION
Foreign body ingestion is a common problem. The vast majority of cases are seen in children, and most
of these involve coins.1,2 Guidelines recommend a more rapid intervention for objects higher up in the
gastrointestinal tract or the esophagus while it may be prudent to wait three to four weeks once the
object has passed into the stomach.1,3,4 On occasion, the ingestion may go unnoticed for months to
years.5,6 We present an unusual case of incidental discovery of ingested foreign body in an adult.
CASE REPORT
A 61-year-old Caucasian female presented to the emergency room with three days of right lower
quadrant abdominal pain that radiated down to her thighs. Associated symptoms included nausea and a
decreased urine output. Past medical history was significant for irritable bowel syndrome, chronic back
pain, diverticulosis, and diabetes mellitus. Past surgical history included appendectomy,
cholecystectomy, and hysterectomy. She had a 90-pack year smoking history, drank alcohol socially, and
denied illicit drug use. She formerly worked as school cafeteria manager. On physical examination, she
was febrile with a temperature of 101.6 ˚F, heart rate was 120/minute, respiratory rate was 16/minute
and blood pressure was 117/65 mmHg. She was in significant distress with right lower quadrant
tenderness on palpation without rebound, guarding or rigidity. Laboratory work-up showed a
leukocytosis of 17,000/mm3, with 18% bands. Urinalysis was consistent with infection. She had renal
insufficiency with a creatinine of 1.3mg/dL. Computerized tomography scan of the abdomen revealed
right-sided obstructive nephrolithiasis with pyelonephritis. A right ureteral stent was placed to relieve
the obstruction and patient was started on broad spectrum antibiotics. Her symptoms resolved over the
ensuing days, as did her laboratory parameters. Of note, imaging studies obtained at admission
incidentally revealed a metallic foreign body in her stomach. This metallic object was still in the proximal
stomach on repeat studies. Although her symptoms had abated, the patient and her family had
continued concern regarding the exact nature of the foreign body, and an
esophagogastroduodenoscopy (EGD) was performed to retrieve it. The metallic foreign body turned out
to be a stack of five coins – four quarters and a nickel – which were stuck together, although freely
mobile as one mass in the stomach. They appeared green and corroded. The coins were separated with
difficulty and were removed individually using a snare. On inquiry, neither the patient nor her family had
any prior knowledge about the ingestion of the coins or any history of pica. A more extensive review of
old radiology records revealed a metallic foreign body resembling a coin noted in the distal esophagus
on chest x-ray five years before.
DISCUSSION
The finding of ingested coins in adults is infrequent, but there have been rare case reports. The most
common type of coin ingested is the penny, followed by the quarter. One report describes an 85-yearold blind female with a history of esophageal stricture who presented with dysphagia and odynophagia
of two days duration.7 She was noted to have three stacked coins lodged in her esophagus that were
retrieved under anesthesia. It was considered to be an inadvertent ingestion due to her blindness.8
Another unusual side effect reported includes anemia and neutropenia as a result of multiple coin
ingestion.9 This was illustrated in a 58-year-old male patient with paranoid schizophrenia with habitual
ingestion of coins. Workup revealed coins throughout the gastrointestinal tract, and these were mostly
pennies. Among United States coins, only the pennies have zinc in their composition (2.5% copper,
97.5% zinc).10 This practice started in 1982 when copper prices started rising. The zinc content in the
coins resulted in copper deficiency that caused subsequent anemia and neutropenia.
Broad guidelines have been provided by the Standards of Practice Committee of the American
Society for Gastrointestinal Endoscopy for the management of ingested foreign bodies.4 These include
endoscopic retrieval of objects lodged in the proximal esophagus, especially if the patient is
symptomatic. In adults, the guidelines recommend endoscopic removal of blunt foreign objects such as
coins if they have not passed through the stomach in three to four weeks.1,4 However late onset of
symptoms and incidental findings of ingested foreign bodies have been reported in adults.5,11,12
Guidelines are less clear on retrieval of foreign bodies under these circumstances. One of these cases
reported the incidental discovery of an English penny in a 74-year-old patient during a routine
colonoscopy with no attributable symptoms or pathology. It was highly oxidized suggesting it had been
there for a long time.11Similarly, our patient seemingly had no adverse effects secondary to the coin
ingestion. She had no evidence of gastric outlet obstruction or narrowing, so it was unclear why the
coins failed to pass onward into the duodenum. Another report by Wright et al., describes ingestion of
souvenir coins from the 1998 World Cup, which were larger and heavier relative to the official U.S.
Treasury coins.8 These coins were noted to be at the gastric outlet and were retrieved endoscopically.
The authors speculate that the weight of the coins impeded their forward movement with peristalsis.
In our patient, the stack of coins included four quarters and a nickel, a total of $1.05. The size of a
penny, nickel and quarter are 19.05mm, 21.21mm and 24.26mm respectively per the U.S. Mint
specifications of currently circulating coins.10 We could speculate along similar lines as Wright et al., that
the coins being stacked together weighed more and had a bigger diameter, which precluded their
forward passage through the stomach.
In the current era of scrutiny over healthcare costs, it is also interesting to reflect on the costs of
mobilizing an advanced endoscopic procedure worth thousands of dollars to retrieve the ingested
foreign bodies. A study by Arms et al.,13 compared the cost effectiveness and safety of endoscopy versus
bougienage as an alternative technique for foreign body removal from the upper gastrointestinal
tract.13,14 Total calculated charges for an upper endoscopy for foreign body retrieval at our institution
are approximately $3,000. The study by Arms et al., noted the hospital charges on average ranged from
$1,884 for successful bougienage to nearly $6,000 for endoscopy.13 The conundrum lies in cases like
ours when the coins are found incidentally, and patients have no overt symptoms attributed to them.
The guidelines are not clear in these circumstances. Understandably, there are driving concerns both in
the patient and the physician to be proactive despite the costs and retrieve the objects, which in our
patient turned out to be worth $1.05. We need more guidelines addressing cases such as these that fall
in the gray areas.
References:
1.
Webb WA: Management of foreign bodies of the upper gastrointestinal tract: update.
Gastrointest Endosc 41:39-51, 1995.
2.
Conners GP, Chamberlain JM, Weiner PR: Pediatric coin ingestion: a home-based survey. Am J
Emerg Med 13:638-40, 1995.
3.
Nguyen VX, Le Nguyen VT, Nguyen CC: Appropriate use of endoscopy in the diagnosis and
treatment of gastrointestinal diseases: up-to-date indications for primary care providers. Int J Gen Med
3:345-57, Nov 2010.
4.
Eisen GM, Baron TH, Dominitz JA, et al.: Guideline for the management of ingested foreign
bodies. Gastrointest Endosc 55:802-6, 2002.
5.
Adams DB: Endoscopic removal of entrapped coins from an intraluminal duodenal diverticulum
20 years after ingestion. Gastrointest Endosc 32:415-6, 1986.
6.
Kirberg AE: Long-standing esophageal foreign body. Gastrointest Endosc 32:304-5, 1986.
7.
Fincher RK, Osgard EM: A case of mistaken identity: accidental ingestion of coins causing
esophageal impaction in an elderly female. Med Gen Med 5:3, 2003.
8.
Wright KD, Potts DJ: Ingested coins. J Accid Emerg Med 16:239-40, 1999.
9.
Hassan HA, Netchvolodoff C, Raufman JP: Zinc-induced copper deficiency in a coin swallower.
Am J Gastroenterol 95:2975-7, 2000.
10.
United States Mint: Coin Specifications. Available at
http://www.usmint.gov/about_the_mint/?action=coin_specifications. Accessed Dec 2, 2012.
11.
Brookes MJ, Brind AM: Coin ingestion, an unexpected finding at colonoscopy: case report. Med
Gen Med 5:8, 2003.
12.
Byrne MF, McVey G, Abdulla K, Patchett S: Successful endoscopic management of subacute
intestinal obstruction presenting 3 years after lodgement of a coin in the duodenal cap. Endoscopy
34:594, 2002.
13.
Arms JL, Mackenberg-Mohn MD, Bowen MV, et al.: Safety and efficacy of a protocol using
bougienage or endoscopy for the management of coins acutely lodged in the esophagus: a large case
series. Ann Emerg Med 51:367-72, 2008.
14.
Conners GP: Esophageal coin ingestion: going low tech. Ann Emerg Med 51:373-4, 2008.
Dr. Sunil is a resident and Dr. Malakoff is an associate professor of Medicine in the Department
of Internal Medicine, University of Tennessee College of Medicine, Chattanooga.
There were no conflicts of interest financial or other involving any of the authors during the
preparation of this manuscript.
For reprints and correspondence, contact Dr. Malakoff in the Department of Internal Medicine,
UT-Chattanooga College of Medicine, Chattanooga, TN; phone: 423-778-2998; fax: 423-778-2611; email:
[email protected].