Radiological Karim
Vessal2,
changes Hossain
A.
Ronaghv3
ABSTRACT The
The
objective
bowel
as
highest
of of
colon
in
1095-1098,
the
Manuchehr
of pica
diagnosis
and
ingested
clay. an
and of
be
of
geophagia
the
by
preexisting
low
the
retardation. bowel
health
the
chance
The
stricture
is well
films,
for
with
the
radiographic
occurrence
of the
of geophagia
particularly
associated
secondary
prolonged due
obstruction
Am.
J.
is
smaller
changes
of intestinal
is demonstrated.
known.
opacification
of detectability
frequently colon,
problem
abnormal
penetration
changes of
on
The
using
pattern
bone-age
as a public
depends
condition.
radiologic
atonic
to
due
Clin.
Nuir.
to 28:
1975.
Pica is a disorder of appetite with an abnormal craving for unusual nonedible substances. The mode of satisfying the abnormal appetite depends on the patient’s environment. Limited access to edible substances drives the affected individual into gratifying his desires with nonedible materials (1). Clay-eating or geophagia is by far the most common manifestation of pica because of the availability of clay which is the most common resource for the patient. The subject was extensively reviewed by Cooper in 1957 (2) and Halsted in 1968 (1). Geophagia is a public health problem. The practice is far from rare in many parts of the world, and is usually seen in phases of life during which there is an increased demand for nutrients, e.g., periods of growth, pregnancy, or lactation (3). Geophagia in infancy may be motivated in part by a desire to explore the outside world. Emotional disturbances and frustrations are also among predisposing factors in older children and adults. Persistent ingestion of clay may lead to severe iron-deficiency anemia, growth retardation and hypogonadism. This is partly because of the substitution of nutrient materials by physiologically inert clay and partly because of chelation of vital trace elements (4). Since the habits associated with geophagia are socially condemned among many ethnic groups, the reliability of the history to be gained from affected patients is often in question. The American
and
improved
Other
are
anemia presence
can
Zarabi4
of geophagia
manifestation
geophagia
iron-deficiency pica
significance
immediate
in the
practice
and
radiographic
an
amounts
in pica’
Journal of Clinical
Nutrition
28: OCTOBER
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
The evaluate jective
purpose of this communication is to radiographic examination as an obmeans for detection of geophagia.
Materials
and
methods
Random
samples
of clay
villages of Fars Province, tively analyzed for the ingredients. Comparative performed
using
an
were
collected
from
different
Southern Iran, and quantitarelative abundance of chemical radiographic densitometry was
aluminum
wedge
filter.
A mixture of autoclaved pooled random samples of clay containing 5, 10, and 20 g of clay mixed in a sugar syrup was given with breakfast to 18 volunteers. Films of the abdomen were made with the volunteers in a supine position after 10 mm, 2 hours and 12 hours, using conventional and low kV radiograms. In a field survey 100 children between 8 and 12 years of
age,
cion
in whom
clinical
of geophagia,
of the
abdomen
Cases
of
Teaching
were
examination
were using
the
enterolithiasis Center
reviewed
to
same
radiographic
from
of
for
aroused
subjected
Pahlavi
pertinent
X-ray
Saadi
and
suspi-
procedures. Hospital
University
history
the
examination (Main
Medical
School)
clinical
data.
Results The absorption coefficient of clay was found to be less than the compact and more than the cancellous bone for similar thickness in the kV range of interest. Abnormal opacification of the gastrointestinal tract in the volunteer group is shown in ‘From
Shiraz, 2
the
Iran. Professor
and
Radiology. the Department ciate Professor
1975,
pp.
Pahlavi
University
Chairman
School
of
Associate Professor of Community of Radiology.
1095-1098.
Printed
the
of
Medicine,
Department
of
and Chairman of Medicine. Asso-
in U.S.A.
1095
VESSAL
1096
Table 1. Abnormal opacification of the stomach was noted in four out of six cases using low penetration film and in all individuals in the 2nd and 3rd groups. There was no detectable opacification of the small bowel on 2-hour films in any group. There was a divergence of findings in the 2nd and 3rd groups on the late films with two out of six positive cases in both groups for normal exposure data and three versus four positive opacifications on low kV films. There was only a rough correlation between the amount consumed and opacification of the colon (Fig. I). The radiographic picture of geophagia in the field survey could be divided into primary findings, i.e., detection of opaque objects and/or amorphous opacification of colonic segments (Table 2, group A), and secondary findings, i.e., hypotonic colon, visceral and skeletal changes due to anemia and increased hematopoietic activity as well as retarded bone age (Table 2, group B). The visualization of abnormal opacification could be improved in four cases using low penetration films (Figs. 2 and 3). Altogether, six cases of enterolithiasis were retrieved from the Radiology Files of Saadi Hospital (about 30,000 X-ray examinations/ year) between 1963 and 1973. All had been operated on for intermittent small bowel obstruction. In each case there was old intestinal stricture due to tuberculosis with secondary enterolithiasis from ingested fruit pits and nonedible particles (Fig. 4). Discussion
opacification
gastrointestinal
Sequence of films
10mm 2hr l2hr
15.1.
ure
and
I.
tract of
of
the
ruizuiiiiai
transverse
20 g of clay.
Low
TABLE 2 100 Cases examined Group
A:
colon
kV
upa.ication 12 hours film.
in a field
No.
Primary I 11
B: Secondary I II
Ill IV
I
Abnormal ingestion
AL.
III
The radiographic picture of geophagia has teen described by Clayton and Goodman (5) and by Gardner and Tevetoglu (6). Heavy
TABLE
ET
in the following
hepatic
flex-
ingestion
of
survey
Finding
No.
findings Opaque Abnormal
foreign
body
fragments
amorphous
13
opacification
Conventional technique Low penetration No immediate finding
7 II 76
radiographic findings Hypotonic Colon Anemic changes (cardiomegaly, splenomegaly, increased hematopoetic activity) Retarded bone age No changes
21 15
13 73
following
clay
Group 1(6) 5g
Groupll(6)
Group
lOg
111(6)
20g
Cony.
Low
Cony.
Low
Cony.
Low
kV
kV
kV
kV
kV
kV
2 0 0
4 0 0
6 0 2
6 0 3
6 0 2
6 0 4
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
opacification of the gastrointestinal described by these authors resulted ingestion of large quantities of clay order of hundreds of grams. These extremely rare and irrelevant to the nity health problem. We have not tered a similar case in the past decade institute, which supplies free medical
tract
as from on the must be commuencounin our care to
RADIOLOGICAL
CHANGES
IN
PICA
1097
the indigent population of Fars Province in Southern Iran, where geophagia is prevalent. According to our experience the average quantity of clay consumed is much less than in the above-mentioned cases, and the visible opacification of the gastrointestinal tract on I
.1 I ‘I 4 FIG. 2. Abnormal colon in a geophagic
eign
FIG. 3. bodies
opacification
child.
Hypotonic colon in the descending
Low
of
kV
the
ascending
film.
and multiple opaque forcolon and rectal ampulla.
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
conventional radiograms is slight or equivocal and can easily be missed if not specially looked for. The chance of detection of ingested clay is obviously highest in the stomach if early films are made. Poorest visibility of clay is in the small intestine because of dilution by the larger volume of intestinal chyle. Optimal opacification occurs in the colon because of water absorption and subsequent inspissation of the colonic contents. The longer transit time contributes to greatly improved chances of radiologic detection. In radiography, contrast to the soft tissue can be improved by using low penetration films because of the higher mean absorption coefficient of clay. Instantaneous detection of opaque foreign bodies with or without abnormal opacification, though a bona fide criterion for geophagia, does not provide a reliable clue as to the habit of geophagia or chronicity of the condition. The type of geophagia which is common among the indigenous rural population in Southern Iran reveals a far more subtle radiographic picture. The abnormal opacification is usually seen in the colon and consists
1098
VESSAL
of a fine speckled opacification in the right half of the colon or homogeneous density when the colonic content reaches the descending colon. In contrast to the volunteer group, the colonic configuration among the geophagic individuals from the field survey showed a frequent association of atonic constipation, sometimes indistinguishable from Hirschprung’s disease. The presence of bizarre opaque particles resulting from ingestion of impure clay is an available clue for suspecting geophagia. Radiographic changes due to increased hematopoietic activity secondary to iron-deficiency anemia and retarded bone-age are additional frequent findings in geophagia, as previously reported from the center, and can easily be detected radiologically. Ingestion of opaque or nonopaque inedible material such as fruit pits or conglomerate clay particles can lead to intestinal obstruction if preexisting small bowel strictures are present. The ingested palm date pits seen in Fig. 4, with a calcified outer shell of varying
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
ET
AL.
thickness, as well as nonopaque pits during surgery, suggest a chronic habit individual who had a healed intestinal culosis and a stricture in the ileum.
found in an tuber-
References I.
J. A. Geophagia: Its nature and nutritional Am. J. Clin. Nutr. 21: 1384, 1968. COOPER, M. Pica. Springfield, Ill.: Thomas. 1957. LANZKOWSKY, P. Investigation into aetiology and treatment of pica. Arch. Disease Childhood 34: 140, 1959. REINHOLD, J. G., B. FARADJI, P. ABADI AND F. ISMAIL-BEIGI. Binding of zinc fiber and other solids of whole meal bread with a preliminary examination of the effects of cellulose consumption upon the metabolism of zinc, calcium and phosphorous in man. In: Proceedings of International Symposium on Trace Elements in Human Disease, Detroit, Michigan. New York: Academic, 1974. CLAYTON, R. S.. AND P. H. GOODMAN. The roentgenographic diagnosis of geophagia (dirt-eating). Am. J. Roentgenol. Radium Therapy NucI. Med. 73: 203, 1955. GARDNER, E. G., ANI) F. TEVETOGLL. The roentgenographic diagnosis of geophagia (dirt-eating) in children. J. Pediat. 51: 667, 1957. HALSTED,
effects.
2. 3.
4.
5.
6.
Vessal2,
changes Hossain
A.
Ronaghv3
ABSTRACT The
The
objective
bowel
as
highest
of of
colon
in
1095-1098,
the
Manuchehr
of pica
diagnosis
and
ingested
clay. an
and of
be
of
geophagia
the
by
preexisting
low
the
retardation. bowel
health
the
chance
The
stricture
is well
films,
for
with
the
radiographic
occurrence
of the
of geophagia
particularly
associated
secondary
prolonged due
obstruction
Am.
J.
is
smaller
changes
of intestinal
is demonstrated.
known.
opacification
of detectability
frequently colon,
problem
abnormal
penetration
changes of
on
The
using
pattern
bone-age
as a public
depends
condition.
radiologic
atonic
to
due
Clin.
Nuir.
to 28:
1975.
Pica is a disorder of appetite with an abnormal craving for unusual nonedible substances. The mode of satisfying the abnormal appetite depends on the patient’s environment. Limited access to edible substances drives the affected individual into gratifying his desires with nonedible materials (1). Clay-eating or geophagia is by far the most common manifestation of pica because of the availability of clay which is the most common resource for the patient. The subject was extensively reviewed by Cooper in 1957 (2) and Halsted in 1968 (1). Geophagia is a public health problem. The practice is far from rare in many parts of the world, and is usually seen in phases of life during which there is an increased demand for nutrients, e.g., periods of growth, pregnancy, or lactation (3). Geophagia in infancy may be motivated in part by a desire to explore the outside world. Emotional disturbances and frustrations are also among predisposing factors in older children and adults. Persistent ingestion of clay may lead to severe iron-deficiency anemia, growth retardation and hypogonadism. This is partly because of the substitution of nutrient materials by physiologically inert clay and partly because of chelation of vital trace elements (4). Since the habits associated with geophagia are socially condemned among many ethnic groups, the reliability of the history to be gained from affected patients is often in question. The American
and
improved
Other
are
anemia presence
can
Zarabi4
of geophagia
manifestation
geophagia
iron-deficiency pica
significance
immediate
in the
practice
and
radiographic
an
amounts
in pica’
Journal of Clinical
Nutrition
28: OCTOBER
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
The evaluate jective
purpose of this communication is to radiographic examination as an obmeans for detection of geophagia.
Materials
and
methods
Random
samples
of clay
villages of Fars Province, tively analyzed for the ingredients. Comparative performed
using
an
were
collected
from
different
Southern Iran, and quantitarelative abundance of chemical radiographic densitometry was
aluminum
wedge
filter.
A mixture of autoclaved pooled random samples of clay containing 5, 10, and 20 g of clay mixed in a sugar syrup was given with breakfast to 18 volunteers. Films of the abdomen were made with the volunteers in a supine position after 10 mm, 2 hours and 12 hours, using conventional and low kV radiograms. In a field survey 100 children between 8 and 12 years of
age,
cion
in whom
clinical
of geophagia,
of the
abdomen
Cases
of
Teaching
were
examination
were using
the
enterolithiasis Center
reviewed
to
same
radiographic
from
of
for
aroused
subjected
Pahlavi
pertinent
X-ray
Saadi
and
suspi-
procedures. Hospital
University
history
the
examination (Main
Medical
School)
clinical
data.
Results The absorption coefficient of clay was found to be less than the compact and more than the cancellous bone for similar thickness in the kV range of interest. Abnormal opacification of the gastrointestinal tract in the volunteer group is shown in ‘From
Shiraz, 2
the
Iran. Professor
and
Radiology. the Department ciate Professor
1975,
pp.
Pahlavi
University
Chairman
School
of
Associate Professor of Community of Radiology.
1095-1098.
Printed
the
of
Medicine,
Department
of
and Chairman of Medicine. Asso-
in U.S.A.
1095
VESSAL
1096
Table 1. Abnormal opacification of the stomach was noted in four out of six cases using low penetration film and in all individuals in the 2nd and 3rd groups. There was no detectable opacification of the small bowel on 2-hour films in any group. There was a divergence of findings in the 2nd and 3rd groups on the late films with two out of six positive cases in both groups for normal exposure data and three versus four positive opacifications on low kV films. There was only a rough correlation between the amount consumed and opacification of the colon (Fig. I). The radiographic picture of geophagia in the field survey could be divided into primary findings, i.e., detection of opaque objects and/or amorphous opacification of colonic segments (Table 2, group A), and secondary findings, i.e., hypotonic colon, visceral and skeletal changes due to anemia and increased hematopoietic activity as well as retarded bone age (Table 2, group B). The visualization of abnormal opacification could be improved in four cases using low penetration films (Figs. 2 and 3). Altogether, six cases of enterolithiasis were retrieved from the Radiology Files of Saadi Hospital (about 30,000 X-ray examinations/ year) between 1963 and 1973. All had been operated on for intermittent small bowel obstruction. In each case there was old intestinal stricture due to tuberculosis with secondary enterolithiasis from ingested fruit pits and nonedible particles (Fig. 4). Discussion
opacification
gastrointestinal
Sequence of films
10mm 2hr l2hr
15.1.
ure
and
I.
tract of
of
the
ruizuiiiiai
transverse
20 g of clay.
Low
TABLE 2 100 Cases examined Group
A:
colon
kV
upa.ication 12 hours film.
in a field
No.
Primary I 11
B: Secondary I II
Ill IV
I
Abnormal ingestion
AL.
III
The radiographic picture of geophagia has teen described by Clayton and Goodman (5) and by Gardner and Tevetoglu (6). Heavy
TABLE
ET
in the following
hepatic
flex-
ingestion
of
survey
Finding
No.
findings Opaque Abnormal
foreign
body
fragments
amorphous
13
opacification
Conventional technique Low penetration No immediate finding
7 II 76
radiographic findings Hypotonic Colon Anemic changes (cardiomegaly, splenomegaly, increased hematopoetic activity) Retarded bone age No changes
21 15
13 73
following
clay
Group 1(6) 5g
Groupll(6)
Group
lOg
111(6)
20g
Cony.
Low
Cony.
Low
Cony.
Low
kV
kV
kV
kV
kV
kV
2 0 0
4 0 0
6 0 2
6 0 3
6 0 2
6 0 4
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
opacification of the gastrointestinal described by these authors resulted ingestion of large quantities of clay order of hundreds of grams. These extremely rare and irrelevant to the nity health problem. We have not tered a similar case in the past decade institute, which supplies free medical
tract
as from on the must be commuencounin our care to
RADIOLOGICAL
CHANGES
IN
PICA
1097
the indigent population of Fars Province in Southern Iran, where geophagia is prevalent. According to our experience the average quantity of clay consumed is much less than in the above-mentioned cases, and the visible opacification of the gastrointestinal tract on I
.1 I ‘I 4 FIG. 2. Abnormal colon in a geophagic
eign
FIG. 3. bodies
opacification
child.
Hypotonic colon in the descending
Low
of
kV
the
ascending
film.
and multiple opaque forcolon and rectal ampulla.
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
conventional radiograms is slight or equivocal and can easily be missed if not specially looked for. The chance of detection of ingested clay is obviously highest in the stomach if early films are made. Poorest visibility of clay is in the small intestine because of dilution by the larger volume of intestinal chyle. Optimal opacification occurs in the colon because of water absorption and subsequent inspissation of the colonic contents. The longer transit time contributes to greatly improved chances of radiologic detection. In radiography, contrast to the soft tissue can be improved by using low penetration films because of the higher mean absorption coefficient of clay. Instantaneous detection of opaque foreign bodies with or without abnormal opacification, though a bona fide criterion for geophagia, does not provide a reliable clue as to the habit of geophagia or chronicity of the condition. The type of geophagia which is common among the indigenous rural population in Southern Iran reveals a far more subtle radiographic picture. The abnormal opacification is usually seen in the colon and consists
1098
VESSAL
of a fine speckled opacification in the right half of the colon or homogeneous density when the colonic content reaches the descending colon. In contrast to the volunteer group, the colonic configuration among the geophagic individuals from the field survey showed a frequent association of atonic constipation, sometimes indistinguishable from Hirschprung’s disease. The presence of bizarre opaque particles resulting from ingestion of impure clay is an available clue for suspecting geophagia. Radiographic changes due to increased hematopoietic activity secondary to iron-deficiency anemia and retarded bone-age are additional frequent findings in geophagia, as previously reported from the center, and can easily be detected radiologically. Ingestion of opaque or nonopaque inedible material such as fruit pits or conglomerate clay particles can lead to intestinal obstruction if preexisting small bowel strictures are present. The ingested palm date pits seen in Fig. 4, with a calcified outer shell of varying
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/10/1095/4716629 by Washington University in St. Louis user on 12 May 2018
ET
AL.
thickness, as well as nonopaque pits during surgery, suggest a chronic habit individual who had a healed intestinal culosis and a stricture in the ileum.
found in an tuber-
References I.
J. A. Geophagia: Its nature and nutritional Am. J. Clin. Nutr. 21: 1384, 1968. COOPER, M. Pica. Springfield, Ill.: Thomas. 1957. LANZKOWSKY, P. Investigation into aetiology and treatment of pica. Arch. Disease Childhood 34: 140, 1959. REINHOLD, J. G., B. FARADJI, P. ABADI AND F. ISMAIL-BEIGI. Binding of zinc fiber and other solids of whole meal bread with a preliminary examination of the effects of cellulose consumption upon the metabolism of zinc, calcium and phosphorous in man. In: Proceedings of International Symposium on Trace Elements in Human Disease, Detroit, Michigan. New York: Academic, 1974. CLAYTON, R. S.. AND P. H. GOODMAN. The roentgenographic diagnosis of geophagia (dirt-eating). Am. J. Roentgenol. Radium Therapy NucI. Med. 73: 203, 1955. GARDNER, E. G., ANI) F. TEVETOGLL. The roentgenographic diagnosis of geophagia (dirt-eating) in children. J. Pediat. 51: 667, 1957. HALSTED,
effects.
2. 3.
4.
5.
6.
