Ann. Pak. Inst. Med. Sci. 2010; 6(2): 127-128

Abstract: Acute abdomen is one of the most common presentations in accident and emergency. It may even be more difficult to recognize abdominal symptoms in schizophrenic patients such patients have eating disorders, associated to delusional ideas and distorted cognitions related to food or body perception. We present an interesting case of acute abdomen, who had swallowed multiple sharp objects, which he denied eating. Later it was revealed that he was a patient of schizophrenia.

Introduction

Schizophrenic patients do present with vague abdominal pain which is related to their eating disorder. In the early nineteenth century, Eugen Bleuler has reported cases of schizophrenia with eating disorders that were related to delusional ideas.¹ The relation between eating disorders and schizophrenia have been underappreciated and poorly studied and are therefore classified as "eating disorders not otherwise specified" (EDNOS). Potomania, merycism and pica have often been described in schizophrenic patients, most frequently in hebephrenic schizophrenia.

Case Presentation

We present a 34 year old gentleman, working as a businessman with well settled family life, with history of schizophrenia but remained symptom free for last 5 years, presented in Emergency Department with on and off abdominal pain for many months gone worse over the last 3 days. On clinical examination he had rigid abdomen with all other signs of peritonitis. An erect chest and abdominal x-ray showed a metallic Rod running from xiphisternum to pubic bone. Patient first denied but later accepted that he had swallowed it. The patient was responding to auditory hallucinations which had asked him to swallow various objects. He also described passivity phenomenon that the voices were controlling his mind. Patient was resuscitated and shifted to Operation Theatre after psychiatric assessment. On exploration variety of objects were found in stomach, which included plastic coated currency notes, biscuit wrappers, plastic sticks, pens, coins, and a solid steel rod. The steel rod had perforated the posterior wall of stomach, which makes it clear that it was swallowed too.

Figure I: Open Stomach with currency note	Figure II: Objects Removed

Discussion

Where dealing with abdominal pain in psychiatric patients an unusual diagnosis of foreign body ingestion should be kept in mind. Deaths have been reported in literature after swallowing sharp foreign bodies ². In literature where little is known about eating Disorders associated with schizophrenia, there is optimism that eating-related symptoms in schizophrenia will disappear as the psychosis abates.

In patients with chronic schizophrenia and eating disorders it is confirmed that there is a distinction between eating disorders of psychotics and eating disorders of the young. Most of the Schizophrenic patients do not full fill the criteria for eating disorder. Eating disorders with schizophrenia are more commonly reported when schizophrenia is associated with delusions than hallucinations. ³

Even beside that these patient do present in general surgical emergency with vague abdominal symptoms and signs but these schizophrenic patients have decreased pain perception and expression.^{4, 5} Because of this they frequently lead to difficulties in the diagnosis of acute abdomen resulting in delayed treatment of a surgical emergency. ⁵
It is therefore very important that surgeons should be acutely aware of the diagnostic dilemmas presented by these patients so that misdiagnosis is avoided and appropriate surgical treatment is started in as soon as possible.

References 

1. Foulon C.  Schizophrenia and eating disorders. Encephale Review. French. 2003 Sep-Oct; 29(5):463-6.
2. Jacob B, Huckenbeck W, Barz J, Bonte W. Death, after swallowing and aspiration of a high number of foreign bodies, in a schizophrenic. Am J Forensic Med Pathol. 1990 Dec; 11(4):331-5.
3. Lyketsos GC, Paterakis P, Beis A, Lyketsos CG.  Eating disorders in schizophrenia. Br J Psychiatry. 1985 Mar;146:255-61
4. Bickerstaff LK, Harris SC, Leggett RS, Cheah KC. Pain Insensitivity in Schizophrenic Patients. A surgical dilemma. Arch Surg. 1988; 123(1):49-51.
5. Murthy BV, Narayan B, Nayagam S. Reduced perception of pain in schizophrenia: its relevance to the clinical diagnosis of compartment syndrome. Injury. 2004 Nov;35(11):1192-3