JAMA Clinical Challenge
October 30, 2023
Coin-Shaped Opacities in the Stomach
Neil Shadbeh Evans, Paul Aronowitz, Timothy E. Albertson
JAMA. 2023;330(20):2016-2017. doi:10.1001/jama.2023.19032
Case
A50-year-old man with end-stage kidney disease receiving hemodialysis was admitted to the hospital for treatment of calciphylaxis and foot cellulitis. His home medications included sevelamer and hydrocodone-acetaminophen (10 mg/325 mg) every 8 hours as needed, which was increased to every 4 hours as needed in the hospital. Hydromorphone (0.5 mg intravenously as needed) was added for breakthrough pain. He was prescribed chewable lanthanum tablets (500 mg 3 times daily) for treatment of a blood phosphate level of 8.1 mg/dL (reference, 2.5-4.5 mg/dL).
On hospital day 7, the patient developed intermittent apneic episodes, during which his oxygen saturation was 80% on room air; heart rate, 86/min; and blood pressure, 106/45 mm Hg. Physical examination revealed bilateral rhonchi and responsiveness to verbal commands only with deep painful stimulus. A chest radiograph showed 4 radio-opaque coin-shaped opacities in the stomach (Figure). After administration of oxygen at 2 L/min by nasal cannula and a naloxone infusion, his oxygen saturation increased to 98% and his mental status improved. The patient reported no foreign body ingestion.
Chest radiograph showing 4 rounded objects in patient’s stomach
What Would You Do Next?
- Administer activated charcoal
- Arrange endoscopy
- Perform gastric lavage
- Provide supportive care
Discussion
Diagnosis
Accidental ingestion of whole lanthanum tablets
What to Do Next
The key to the correct diagnosis is recognizing that ingestion of whole lanthanum tablets may cause radio-opaque coin-shaped opacities on imaging studies. Activated charcoal (choice A) and gastric lavage (choice C) are not needed because the patient did not ingest a known toxin. Endoscopy (choice B) is not warranted because the patient had no signs or symptoms of esophageal or gastric outlet obstruction and had no sharp-pointed objects in his esophagus, stomach, or duodenum.
Discussion
Foreign body ingestion includes ingestion of true foreign objects and food bolus impaction. Approximately 100 000 cases of upper gastrointestinal tract foreign body ingestion are reported annually in the US, with 80% occurring in children, most commonly between the ages of 6 months and 3 years.1-3 Foreign body ingestion in adults is typically due to food bolus impaction and is often associated with esophageal dysmotility, edentulism, and developmental delay.1,2 Accidental foreign body ingestion can occur in adults with intoxication or cognitive impairment.2 Intentional foreign body ingestion typically occurs in adults with psychiatric disorders, incarcerated individuals seeking release to a medical facility, and those who swallow packets of illicit drugs (“body packing”).1
Most patients with foreign body ingestion are asymptomatic, and most ingested foreign objects pass through the gastrointestinal tract without clinical consequences within 4 to 6 days after reaching the stomach. However, gastrointestinal tract obstruction, perforation, infection, hemorrhage, fistula, or foreign body migration through the digestive wall occur in 1% to 5% of patients with foreign body ingestion.2,4,5 These complications often involve areas of gastrointestinal tract narrowing or angulation and are more common in patients with esophageal disorders such as eosinophilic esophagitis or in those with esophageal stenosis, webs, or diverticula or previous gastrointestinal surgery or congenital gut malformations.1,5 The diagnosis of foreign body ingestion is made with plain radiography to assess the size, location, configuration, and number of ingested radio-opaque objects. Computed tomography imaging is recommended for all patients with foreign body ingestion who have suspected gastrointestinal tract perforation or other complications that may require surgery.2,5
The most common causes of imaging-identified coin-shaped objects in the gastrointestinal tract are coins, batteries, magnets, and certain medications such as barium, lanthanum, and potassium chloride tablets.4,6,7 The most common radiopaque ingested foreign bodies are metal objects, such as coins, screws, pins, magnets, button-shaped batteries, and nails.2 Lanthanum, a rare earth metal closely related to barium, is a radiopaque phosphate binder that is excreted through the gastrointestinal tract and can be administered as a chewable tablet or as an oral powder. Lanthanum is frequently prescribed for patients with chronic kidney failure and severe hyperphosphatemia and has been reported to cause opacities throughout the gastrointestinal tract on imaging studies.7 Common adverse effects of lanthanum include nausea, vomiting, ileus, and diarrhea.7,8
The American Society for Gastrointestinal Endoscopy recommends emergent therapeutic esophagogastroduodenoscopy (EGD) within 2 to 6 hours of presentation for foreign bodies that cause complete esophageal obstruction or for sharp-pointed objects or batteries located in the esophagus. Urgent EGD, performed within 24 hours, is recommended for nonobstructing foreign bodies in the esophagus; for sharp-pointed foreign bodies, batteries, and objects longer than 6 cm in the stomach or duodenum; and for magnets within endoscopic reach.1,9 Nonurgent EGD, performed within 72 hours, is recommended for blunt objects in the stomach that are larger than 2.5 cm in diameter. Patients with symptomatic ingestion of blunt small objects (other than batteries and magnets) should observed without EGD.1,5,9
Foreign body ingestion associated with hemodynamic instability, severe sepsis, and noncontained extravasation of contrast material requires immediate surgical treatment. Surgery may also be recommended if EGD cannot be performed or if endoscopy fails to extract an ingested foreign body.2,5
Patient Outcome
Because the patient’s increased opioid dosing frequency caused apneic episodes that led to accidental ingestion of whole lanthanum tablets, hydrocodone-acetaminophen (10 mg/325 mg) was decreased to every 8 hours as needed and intravenous hydromorphone was stopped. Although ultimately not necessary, an abdominal computed tomography scan performed on the same day as the chest radiograph demonstrated dissolving round objects, consistent with ingestion of unchewed lanthanum tablets. The patient did not develop nausea, vomiting, or diarrhea, so lanthanum was continued during his hospitalization with clear instructions that these tablets should be chewed prior to swallowing them. At hospital discharge, his phosphate level was normal (3.3 mg/dL). Lanthanum was discontinued, and he continued sevelamer and his home opiate regimen.