Lithophagia

A 48-year-old homeless man with no known medical history presented to the emergency department complaining of lower abdominal pain, constipation, and intermittent hematochezia of 2 weeks’ duration. The patient’s vital signs were stable and no conjunctival pallor was seen. His abdomen was soft, non-tender, and slightly distended with normo-active bowel sounds. No masses were detected. Results of routine laboratory test were within normal limits except for a slightly elevated white blood cell count of 14.2 x 10³/µL, with 86% neutrophils.

Abdominal x-ray films showed small radio-opaque foreign bodies scattered throughout the entire colon.

The patient admitted to having ingested small pebbles and gravel over the past 9 months, with the belief that "God might turn it to bread in his belly.”

The patient underwent a purge with polyethelene glycol-electrolyte solution but some of the pebbles became impacted in the rectosigmoid colon. Manual disimpaction was performed under general anesthesia. Symptoms improved and a series of radiologic follow-up studies showed near-complete clearance of the pebbles.

After inpatient psychiatric evaluation, the patient was given a diagnosis of a nonspecific delusional disorder. Treatment was initiated with aripiprazole. Outpatient follow-up was arranged at a free clinic but the patient failed to attend.

Discussion
Pica is a persistent appetite for nonnutritive substances, such as clay or dirt (geophagia) or paper products or starch (amylophagia).^1,2 Lithophagia (eating rocks and pebbles), is a form of geophagia. Geophagia is not uncommon in southern parts of the US and in urban Africa.³ In the setting of famine and poverty, consuming earth matter may serve as an appetite suppressant or filler.³ Geophagia has also been recorded in patients with anorexia nervosa.³ However, this behavior is usually associated with pregnancy and iron deficiency anemia^3,4 and with mental retardation and obsessive-compulsive disorder.⁴ It can present with abdominal pain, constipation, and hematochezia, as in our patient’s case.

Complications of geophagia are generally linked to the amount of ingested material. They include parasitic infestation, electrolyte imbalance, and intestinal obstruction.³ Complications specific to lithophagia include bowel obstruction, and one can speculate bowel perforation and dental problems.⁵

A review of the English-language literature listed in PubMed found only 2 cases of lithophagia (as distinct from geophagia).^4,6 One was a patient in India who had mental retardation⁴ and the other was a patient in Arizona who suffered from bipolar disorder and who required colonoscopic intervention to remove the stones.⁶
 

References:

References
1. Simpson E, Mull JD, Longley E, East J. Pica during pregnancy in low-income women born in Mexico. West J Med. 2000;173:20.
2. Kettaneh A, Eclache V, Fain O, et al. Pica and food craving in patients with iron-deficiency anemia: a case-control study in France. Am J Med. 2005;118:185-188.
3.Woywodt A, Kiss A. Geophagia: the history of earth eating. J Royal Soc Med. 2002;95:143-146.
4. Somalwar A, Dave KK. Lithophagia: pebbles in and pebbles out. J Assoc Physicians India. 2011;59:170.
5. Johnson CD, Shynett B, Dosch R, Paulson R. An unusual case of tooth loss, abrasion, and erosion associated with a culturally accepted habit. Gen Dent. 2007;55:445-448.
6. Shahverdian DE, Mariyappa A, Wisinger D, Ravi J, et al. Successful removal of cecal stones by using a colonoscope in an individual with repeated lithophagia. Gastrointest Endosc. 2009;69:1188-1190.