A 3-year old female is seen in the E.D. in the 
evening with a chief complain of stomach pains and 
vomiting.  She vomited 5 times since yesterday.  The 
pain is located in the epigastrium.  The emesis is 
described as what she just ate, not bloody and not 
bilious.  She has no diarrhea.  Her last bowel movement 
occurred yesterday.  She has no fever.  Her parents 
describe her activity as decreased.  She is taking 
Pepto-Bismol (bismuth subsalicylate) and Donnatal 
(phenobarbital, hyoscyamine, atropine. scopolamine).  
Her parents have not noticed any improvement with 
these medications.
     Exam:  VS T36.9 (tympanic), P98, R24, BP 114/62.  
Alert, active, cooperative, quiet, and sad-appearing.  
Eyes clear.  Oral mucosa moist.  TM's normal.  Neck 
supple.  Heart regular, grade 1/6 systolic ejection 
murmur.  Lungs clear.  Abdomen soft, flat, bowel 
sounds active.  No hepatosplenomegaly.  Mild diffuse 
tenderness.  No rebound.  No masses.  No hernias.  
Normal female genitalia.  No CVA tenderness.  Color, 
turgor, and perfusion are good.
     An abdominal series is ordered.

View abdominal series:  Flat (supine) view.

View abdominal series:  Upright view.

     This abdominal series shows a normal pattern of 
gas distribution.  There are no areas of excessive bowel 
dilation.  There are no air fluid levels.  There are no 
mass effects.  There is a moderate degree of stool in 
the colon.  There are also some faint calcifications best 
seen in the right upper quadrant on the upright view.  
To see this, you will have to enlarge the image, turn 
down the room lights, and adjust the contrast and 
brightness on your monitor.  This is best seen on the 
focused magnified view below.

View calcification close-up. 

     This focused view of the right upper quadrant 
demonstrates faint calcifications which appear to be 
within the bowel lumen.  The parents are asked for 
more details about her recent diet and nothing sounds 
unusual.
     This "calcification" is actually not calcium.  The 
bismuth in the Pepto-Bismol is slightly radiopaque.  
Patients who are taking Pepto-Bismol will have this 
finding on their abdominal radiographs.  Other 
substances that may be radiopaque include ingested 
dirt, sand, and dental debris.  Other agents that 
may be radiopaque include (C.H.I.P.E.S):  Chloral 
hydrate/Calcium, Heavy metals (lead, arsenic, etc.), 
Iodides/Iron (vitamin pills), Phenothiazines and 
Psychotropics, Enteric coated tablets, and Slow-release 
capsules.
     She is given an enema.  She passes a large stool.  
Her abdominal pain resolves.  She is discharged from 
the emergency department with the usual vomiting 
instructions to maintain her hydration and return if her 
condition worsens.