Lithophagia: Presenting as spurious diarrhea.

Dear Editor,

We are presenting to you a 42-year-old female who presented with multiple episodes of small volume, mucoid diarrhea for 5 days, and mild generalized abdominal pain for 1 day to our emergency department. She had developed psychotic symptoms following the recent death of her sibling. She was living alone in an old age home. Clinical examination revealed a dehydrated, thinly built woman with a depressed sensorium, and louse infestation. Her abdomen was soft, minimally tender with sluggish bowel sounds. Imaging of her abdomen showed radioopaque particles in the entire large bowel with a densely packed rectum [Figure 1]. On per rectal examination, numerous small stones were recovered [Figure 2]. On retaking the history, it was found that she had a habit of consuming pebbles from childhood. On psychiatric evaluation, the diagnosis of paranoid schizophrenia was made and her lithophagia was attributed to the same.

Figure 1

Radiograph of abdomen showing radioopaque material densely packed in the rectum, descending colon and transverse colon

Figure 2

Stones recovered from the rectum after digital rectal disimpaction

Pica is a disorder characterized by persistent eating of nonnutritive substances, for at least 1 month, at an age for which it is developmentally inappropriate. It can have a clinically benign course or can be life-threatening.[1] It has commonly been associated with iron deficiency, zinc deficiency, developmental delay, mental retardation, and family history of Pica.[2] Common substances consumed include clay, matches, stones, hair, and feces.[3] Manifestations of toxicity, secondary infection, gastrointestinal complications, or dental complications usually cause the patient to seek medical intervention.[3]

Our patient was managed conservatively with adequate hydration and serial rectal evacuation aided by stool softeners. She was started on antipsychotic therapy and had a good clinical response. At discharge, repeat radiograph revealed a significant reduction of stone burden [Figure 3].

Figure 3

Radiograph of abdomen after numerous digital rectal disimpaction

We bring your attention to this case because of the rarity of such a presentation and nonavailability of literature to suggest possible management for such a case. There will always be a dilemma whether such a patient needs to undergo surgical management or be dealt with a wait and watch approach. In our case, we successfully managed the patient conservatively which resulted in the near completion evacuation of the rectum.

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