Intractable Nausea in a Young Woman

The 26-year-old patient has a history of type 1 diabetes; no other prior medical or surgical history. Antiemetics have failed. Can you Dx?

Figure. Please click on image to enlarge.

A 26-year-old woman with a long history of type I diabetes mellitus (DM) presents to the emergency department with 6 days of severe nausea and anorexia. There has been no vomiting, abdominal pain, diarrhea, dysuria, fever, or other symptoms. She has no other prior medical or surgical history and was taking only insulin until her doctor recently started her on compazine and then phenergan, neither of which has helped relieve her nausea.

On physical exam she is in moderate acute distress with normal vital signs except for mild tachycardia, holding an empty emesis bag and occasionally having dry heaves. Her head and neck exam are normal except for a slightly dry appearing tongue. Her abdominal exam is benign with no palpable mass, tenderness, rebound, or guarding.

Blood is sent to the lab to ascertain a possible cause for the nausea such as hyponatremia, renal failure, ketoacidosis, infection, or pregnancy. A CBC, Chem-12, UA, and pregnancy test all are  normal. Although it is typically low yield in a case like this, a KUB (kidneys, ureter, bladder) x-ray is ordered since no other cause has been found and the patient’s symptoms have shown no improvement after 6 days of conservative management, including multiple antiemetics.

The plain film of the abdomen is shown in the Figure, above right; click image to enlarge.

What pathologic finding is noted is noted on the KUB?  

(Hint: there are 12 foreign bodies noted on this film, two are inside the patient.)

Please leave your impresssions below; for answer and discussion, click here.

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