A 38-year-old woman presented to the department of general surgery, Kasturba Medical College Hospital, Manipal, on 15th may 2002, complaining of repeated episodes of abdominal pain, vomiting and loss of consciousness for the past 2 years. She was a tailor by profession.
She had first suffered from an attack of severe abdominal pain 2 years previously, while standing in the bus terminus. Shortly afterwards, she vomited and fell down unconscious and remained so for 2 to 5 minutes. On regaining consciousness, she could not recollect the details of the episode. Medical help was sought but no alleviation was found for her symptoms. She had 6 such episodes over a period of 2 years. The last episode occurred 15 days prior to her hospitalization at our institution. Her abdominal pain was spasmodic and localized to the umbilical area and the lower abdomen. It was mild to moderate in intensity. However, she occasionally experienced severe pain in the epigastric region, associated with vomiting and a peculiar sensation which permeated throughout the same area. This was invariably followed by loss of consciousness for 2 to 5 minutes. After regaining consciousness, she could not recollect ictal events. During such episodes, she experienced neither incontinence of the bowel or bladder, nor generalized tonic-clonic seizures. Post ictal automatism was absent. Patient initially was not aware of the importance of the epigastric pain. Soon she understood the sequence of events and was able to avoid falling down.
In 1990, she was diagnosed with pulmonary tuberculosis and treated with a standard course of drugs for 6 months. She is married with two children. Both were normal vaginal deliveries. After the birth of her second child, she underwent post-partum sterilization in 1991. There was no other significant medical history.
On examination, she was found to be moderately built and moderately well nourished. Abdominal examination did not reveal any abnormality. The examination of the central nervous system was also normal. All other examinations were also within normal limits.
Hemogram was normal. ESR (Erythrocyte Sedimentation Rate) was 14 mm at the end of the first hour. Urine microscopy showed 2 - 4 WBC/hpf, and 0-1 RBC/hpf. Urine culture showed the presence of E-coli 105 cfu/mL. The ultrasound examination of the abdomen, kidney, ureter and bladder was normal. Blood, renal and liver functions were normal. Serum amylase and lipase were within normal limits. Screening for porphyria was done and it was also normal. In view of the presence of RBCs in the urine and spasmodic pain in the abdomen (in spite of the ultrasound examination of the abdomen being normal), she underwent an intravenous urogram. It was normal, but incidentally a needle was found in her abdomen at the L3 level on the left side (Fig. 1 and 2). However, this finding alone could not explain her fainting attacks. Psychiatric evaluation did not reveal any functional abnormality. She was further evaluated with a CT scan of the brain and EEG (Electro Encephalo Gram). The CT scan of the brain was normal. The EEG revealed the presence of right fronto-temporal sharp waves with secondary generalized spike wave discharges, especially precipitated by hyperventilation. She was prescribed 300 mg eptoin tablets, to be taken at night. The patient willfully expressed the desire to have the foreign body removed, in spite of our telling her that it might not be the cause of her abdominal pain. Laparotomy was done 15 days later and the needle was recovered from the root of the transverse mesocolon on the left side. It was brittle and it broke while we were trying to remove it (Fig. 3). The postoperative period was uneventful. Eptoin administration was continued. She is currently being followed-up. To date, she has not suffered from any further episodes.