Journal of Gastrointestinal & Digestive System
Open Access

Abstract

Pica disorder is the ingestion of non-nutritive items often implicated in Iron-Deficiency Anemia (IDA). We present a 48-year-old female presented with worsening fatigue and shortness of breath that concurrently started eating one bag of unpeeled lemons daily for two months. The patient had normal vital signs and mild jaundice. Labs showed hemoglobin 3.3 g/ dl, micro-cytosis and elevated liver enzymes. Computed tomography of the abdomen showed hepatomegaly, mild nodularity of the liver, splenomegaly and was negative for ascites. Further workup showed IDA and anti-mitochondrial antibodies >1:40. Esophagogastroduodenoscopy showed multiple esophageal varices, without active bleeding. The patient declined liver biopsy. Her craving for lemons, shortness of breath resolved after blood transfusion and she was started on ursodeoxycholic acid. Five months after discharge, she continues to do well. IDA is a common finding in PBC, 85% of PBC patients experience fatigue during the course of the disease. We present this case because of the subtle, non-classical presentation of pica which is implicated in IDA and was initially missed in the outpatient clinic. It is our understanding that only one case of pica presenting with craving for unpeeled lemons has been reported. Iron deficiency anemia can occur in patients who appear to have early stage PBC. Screening for GI bleeding is indicated, even in the absence of overt bleeding, since affected patients are at risk of severe portal hypertension despite normal bilirubin levels and absence of cirrhosis on liver biopsy. Therapy begins with iron replacement therapy. In cases of refractory pica, selective serotonin reuptake inhibitors and a formal mental health referral may be warranted.

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