S3443 Recurrent Acuphagia: Endoscopy or Not?

Abstract

INTRODUCTION: Acuphagia is uncontrollable ingestion of metal or sharp objects. It is a psychiatric disorder. Few cases of recurrent acuphagia are reported in literature. We describe the case of a 27-year-old lady with recurrent episodes and the dilemma faced in management. CASE DESCRIPTION/METHODS: 26-year-old lady with a past medical history multiple psychiatric disorders and an 8 year history of recurrent radio-opaque foreign body ingestion. She ingested a screw driver shaft and had previously ingested razor blades, 60 paper clips, spoons, bobby pins, pens, phone stylus. She required many esophagogastroduodenoscopies(EGDs) .Open laparotomy was done once for gastric perforation. Recurrent ingestion was related to craving anesthetic agents as a means of relieving anxiety. At review, her vital signs were stable. The foreign body was visualized on x ray and successfully removed from the stomach using a snare at EGD.Her medications were adjusted by psychiatry. She represented a month later after swallowing an unfolded paper clip confirmed on imaging. Due to lack of symptoms and adjudged low risk, EGD was not done, leaving her dissatisfied. DISCUSSION: Foreign body ingestion is more common in children compared to adults. Adult foreign body ingestion is increasing.(1) Recurrent intentional ingestion is more common in the elderly, prisoners and people with underlying psychiatric disorders.(2) Acuphagia is a form of pica, the consumption of non-nutritious substances. This patient had many psychiatric diagnoses. Most foreign bodies pass through the gastrointestinal tract spontaneously. Some require intervention. European guidelines recommend conservative management for asymptomatic patients with ingestion of small, blunt objects (except batteries and magnets)(3). Indications for endoscopy include symptomatic patients, ingestion of sharp or pointed materials, batteries, magnets and large substances. Those with complications, for example perforation, intestinal obstruction require surgery. Our patient required multiple upper gastrointestinal endoscopies. Although largely asymptomatic, she mainly ingested sharp metal objects that put her at a risk for perforation.Managing this patient was challenging due to multiple presentations. Medication readjustments to manage anxiety thereby preventing recurrences were not fully successful. The threshold for endoscopy was raised. Propofol is being avoided for endoscopy as much as possible as this was the specific agent she craved.Figure 1Figure 2