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
