Bismuth Subsalicylate (Pepto Bismol) Mimicking Foreign Body Ingestion

Abstract

Purpose: Bismuth Subsalicylate (Pepto Bismol), a common over the counter medication, can present as a radiolucent foreign body in imaging studies mimicking foreign body ingestion. Case: 47 year old Jamaican male without any significant medical history presented to the ED with one month history of diffuse abdominal pain, nausea, vomiting and unintentional weight loss. The patient denied taking any prescribed or over the counter medications or ingesting any foreign bodies. Physical examination was normal. Initial workup with Abdominal X ray followed by CT scan of the abdomen revealed the presence of radiopaque foreign bodies in the stomach suggestive of button batteries and large amount of food debris in stomach suggestive of partial gastric outlet obstruction. Upper endoscopy was performed and Bismuth Subsalicylate tablets were found. No metallic foreign bodies were identified within the large amount of retained food particles. A pyloric stricture was noted. Biopsies confirmed the presence of carcinoma at the pylorus. After the endoscopic procedure the patient recalled he had taken Bismuth Subsalicylate for his abdominal symptoms. Discussion: Bismuth is a metal, its free element is 86% as dense as lead and it shares radiopaque properties with barium and lead. Our case illustrates that these medications should be in the differential diagnosis of ingested radiopaque foreign bodies. Several medications have been reported to be radiopaque including Chlorine, Chloral Hydrate, Heavy Metals (Lead, Chromium and Cadmium), Iron, Phenothiazines and sustained releases medications.Figure 1Figure 2