В Южной Африке хирургам пришлось удалять из желудка пациента горсть гвоздей и монету, которую не выявили сканы

Nails Came Out of His Stomach in Surgery, and Then a Coin Turned Up That No Scan Had Caught A 36-year-old man arrived at a hospital in South Africa with a painful swelling on the right side of his lower chest and abdomen that had been draining pus, on and off, for three months. He was already being treated for pulmonary tuberculosis. What his surgeons eventually removed from him was a handful of nails. His case opens a three-patient series on acuphagia published in the South African Journal of Surgery. Acuphagia is the intentional swallowing of sharp metal objects, a form of pica that surgeons rank among the riskiest things a person can put into the gastrointestinal tract. The strangest detail in the case arrived after the operation rather than before it. A Chest Abscess That Was Really a Stomach Problem On examination, the man was stable and had no fever. Doctors found a draining abscess over the right chest wall with swelling, darkened skin and tenderness, and reduced breath sounds in the lower right lung. His abdomen seemed clinically unremarkable, though the inflammation had spread from the chest wall into the right upper quadrant of the abdominal wall. A chest X-ray taken earlier at another facility had raised the possibility of metallic foreign bodies. Follow-up imaging confirmed multiple metal objects sitting in the stomach and the upper small intestine. Cultures from the draining pus grew Escherichia coli and Aeromonas caviae, both of which were sensitive to ciprofloxacin. Surgeons took him to theatre to drain the abscess. Using fluoroscopy, they confirmed the presence of sharp metal objects in the stomach and duodenum, then opened the abdomen via an upper midline incision. They cut into the stomach and removed several nails from the stomach and duodenum. There was no perforation. The stomach was closed in two layers, and the abscess cavity was cleaned and packed. Then a Coin Turned Up That Nobody Had Charted Recovery did not go smoothly. The man developed a persistent wound infection with fluid collecting in the right upper quadrant, which stretched his hospital stay considerably. A later gastroscopy found a duodenal ulcer and a coin. Intraoperative fluoroscopy had not flagged it. The authors suspect the patient swallowed the coin while in hospital, after the surgery but before the endoscopy. It was removed during the scope. A psychiatric evaluation was requested. The man denied swallowing the nails at all. He did admit to swallowing the coin, and attributed the episode to witchcraft. He was discharged for psychiatric follow-up and continued wound care. That mismatch between what patients report and what imaging shows runs through the whole series. Patients often deny swallowing anything, give inconsistent accounts, or blame their symptoms on something else, which is a large part of why diagnosis gets delayed. In this first case, the delay allowed a chronic infection to open spontaneous tracks through the skin, a picture that can easily be mistaken for other serious illness. Two Other Patients, Two Very Different Endings The second patient was a 21-year-old man who intentionally swallowed a sewing needle and had swallowed objects before, including a needle previously retrieved through a proctoscopy. He arrived stable and without symptoms, and an abdominal X-ray showed the needle near the pylorus with no sign of obstruction or perforation. Doctors watched him with repeated abdominal examinations and daily imaging. Stool inspection confirmed the needle passed on its own several days later, and he was discharged with a psychiatric referral. The third was a 61-year-old woman with schizophrenia who was also being treated for HIV and high blood pressure. She had spent four days with difficulty swallowing and the sensation of something stuck in her throat, worse when lying down. A lateral X-ray of her cervical spine showed a metal object in front of the C5 and C6 vertebrae, consistent with a foreign body lodged in the hypopharynx. Blood tests showed metabolic alkalosis with low sodium, potassium, and calcium. She started intravenous antibiotics and electrolyte correction, and on day three surgeons removed the needle through the pharynx under general anesthesia without complications. The Part of the Treatment That Keeps Getting Postponed Psychiatric illness featured in all three cases, and the authors argue that this is the piece most often left undone. They cite reports in which recurrence approaches one-third, noting that acuphagia is closely tied to conditions including schizophrenia and the obsessive-compulsive spectrum. Psychiatric assessment is frequently delayed in public health systems where mental health resources are stretched. Surgery, in their framing, fixes the emergency while leaving the cause untouched. The series also shows how much depends on imaging. Plain X-rays remain the workhorse for suspected metal ingestion in resource-limited settings, but they cannot show non-metallic material or reliably reveal complications. For stable patients, the authors point to computed tomography, which has reported sensitivities above 90 percent for locating foreign bodies and spotting early perforation or abscess. This is a three-patient series from one hospital group, so it cannot say how common these outcomes are. What it illustrates is a treatment ladder running from watchful waiting to endoscopic retrieval to open surgery, consistent with ASGE guidance and the European Society of Gastrointestinal Endoscopy guideline. Research on upper gastrointestinal foreign bodies has found that sharp objects carry higher complication risk than blunt ones. For families, the practical message is narrow. Swallowing a sharp object is an emergency and needs same-day medical assessment rather than watchful waiting at home. Anyone who repeatedly swallows objects needs a mental health evaluation alongside the surgical one. Key Questions Answered What is acuphagia? It is the intentional swallowing of sharp metal objects such as nails, needles, or pins. Doctors classify it as a form of pica, the eating of non-food substances. How were the nails found? An earlier chest X-ray flagged possible metal. Follow-up imaging confirmed multiple metal objects in the stomach and upper small intestine, and fluoroscopy during surgery located them. Where did the coin come from? The authors suspect the patient swallowed it in hospital after the operation and before the endoscopy. It was not noted on intraoperative fluoroscopy, and he later admitted swallowing a coin. Does every swallowed object require surgery? No. One patient in this series passed a sewing needle on his own under daily imaging. Surgery was reserved for the patient with multiple sharp objects and an infected abscess. Is this a common problem? No. Acuphagia is rare, and this report describes three patients treated by one surgical group. It cannot estimate how often these complications occur. Why does psychiatric care matter here? The authors report recurrence approaching one third in some published reports and argue that without mental health treatment, patients return with the same problem. Published by Medicaldaily.com