Images in Emergency Medicine
Article Outline
An 18-month-old girl presented to the emergency department after a 1-day history of multiple episodes of emesis and an unusual appearance of her stool. The patient and her family had been vacationing at the beach during the previous week. She had no significant medical history and was receiving no medications. Physical examination revealed a playful well-hydrated child with normal cardiac and respiratory findings. The abdomen was soft, nontender, and nondistended, with normoactive bowel sounds. There were no palpable masses or hepatosplenomegaly. The initial abdominal radiograph is shown in the Figure.
Figure.
Supine radiograph of the abdomen reveals hyperdense material in lower abdominal bowel loops (arrows), with dilation in the upper abdominal bowel loops, concerning for small-bowel obstruction. Used with permission of Faiqa Quershi, MD, Department of Pediatric Emergency Medicine, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, VA.
Diagnosis
Small-bowel obstruction as a result of sand pica
The radiograph demonstrates partial small-bowel obstruction as a result of sand in the bowel lumen. Further questioning revealed that the child had been caught ingesting handfuls of sand throughout her vacation. A CBC count revealed a microcytic anemia.
The child was admitted and given serial tap water enemas, which eventually cleared the obstruction. Within 24 hours, she was tolerating oral feedings without any further episodes of emesis or diarrhea.
Pica is defined as the persistent eating of nonnutritive substances for a period of at least 1 month, without any association with an aversion to food.1 The definition can be broadened to encompass any behavior manifested by the eating of a nonfood that is unusual in kind or quantity,2 including ice (pagophagia), hair, plaster, clay or dirt (geophagia), laundry and corn starch (amylophagia), ashes, and cigarette butts. There are only a few case reports specifically associated with sand.3, 4
The cause of pica remains unclear.5 The postulated explanations include variances of cultural or folk medicine practice, nutritional deficiencies such as zinc or iron, psychiatric disturbances, sensory appeal (enjoying the smell, texture, or taste of the item), starvation, or a combination of these factors.
In most cases, the behavior is discovered when the patient develops complications such as anemia, lead poisoning, metabolic derangements, or, as in this case, partial intestinal obstruction.
Treatment for pica includes education, nutritional and psychological counseling, or behavior modification therapy,5 plus the treatment of complications.
References
- . Diagnostic and Statistical Manual of Mental Disorders: DSM IV. Washington, DC: American Psychiatric Association; 1994;
- Pica. J R Soc Health. 1997;117:280–284
- . Sandy faecal impaction cause by severe pica. Trop Geogr Med. 1983;35:393–394
- . Sub-acute intestinal obstruction by river sand [case report]. Trop Doct. 2001;31:234
- . Pica: common but commonly missed. J Am Board Fam Pract. 2000;13:353–358
For the diagnosis and teaching points, see page 386.
To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com
PII: S0196-0644(06)00797-9
doi:10.1016/j.annemergmed.2006.06.004
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
