{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T01:51:36Z","timestamp":1785462696088,"version":"3.56.0"},"reference-count":20,"publisher":"BMJ","issue":"5","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2019,4,27]]},"published-print":{"date-parts":[[2019,5]]},"abstract":"<jats:p>A 50-year-old woman presented with worsening fatigue and shortness of breath. For 2\u2009months, she has been having increased craving for unpeeled lemons and was seen in clinic about a month prior to presentation at the emergency room. At that time, she was asymptomatic except for endorsing craving for lemons. Physical exam findings at presentation noted obesity, sinus tachycardia, pallor, mild scleral jaundice and no other stigmata for chronic liver disease. Her labs suggested iron-deficiency anaemia (IDA), elevated liver enzymes and positive antimitochondrial antibody titre. Abdominal ultrasound and CT scan showed mild scarring. She was diagnosed with primary biliary cholangitis with portal hypertension complicated by oesophageal varices and IDA. Interventions included blood transfusion, oesophageal banding and treatment with ursodeoxycholic acid. Her craving for lemons, shortness of breath and fatigue resolved within 1\u2009week. With ongoing outpatient follow-up and oesophageal variceal surveillance, she continues to do well.<\/jats:p>","DOI":"10.1136\/bcr-2018-227316","type":"journal-article","created":{"date-parts":[[2019,5,30]],"date-time":"2019-05-30T06:35:10Z","timestamp":1559198110000},"page":"e227316","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":4,"title":["Unusual presentation of pica in iron-deficiency anaemia associated with primary biliary cholangitis"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9821-0265","authenticated-orcid":false,"given":"Nneoma Kate-Joan","family":"Onuorah","sequence":"first","affiliation":[{"name":"Internal Medicine, Wright State University, Dayton, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melinda","family":"Wayde","sequence":"additional","affiliation":[{"name":"Gastroenterology, Wright State University, Dayton, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory","family":"Beck","sequence":"additional","affiliation":[{"name":"Gastroenterology, Wright State University, Dayton, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2019,5,29]]},"reference":[{"key":"2025082710264122000_12.5.e227316.1","first-page":"20","article-title":"PICA Disorders are dentists aware","volume":"1","author":"Richa","year":"2015","journal-title":"Int J Adv Dent Res"},{"key":"2025082710264122000_12.5.e227316.2","first-page":"356","article-title":"Pica: common but commonly missed","volume":"13","author":"Rose","year":"2000","journal-title":"J Am Board Fam Pract"},{"key":"2025082710264122000_12.5.e227316.3","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra043898"},{"key":"2025082710264122000_12.5.e227316.4","first-page":"108","article-title":"The importance of gastric hydrochloric acid in the absorption of nonheme food iron","volume":"92","author":"Bezwoda","year":"1978","journal-title":"J Lab Clin Med"},{"key":"2025082710264122000_12.5.e227316.5","doi-asserted-by":"crossref","first-page":"563","DOI":"10.3748\/wjg.v23.i4.563","article-title":"Micronutrient deficiencies in patients with chronic atrophic autoimmune gastritis: A review","volume":"23","author":"Federica","year":"2017","journal-title":"World J Gastroenterol"},{"key":"2025082710264122000_12.5.e227316.6","first-page":"13","article-title":"Chronic atrophic gastritis and Helicobacter pylori infection in primary biliary cirrhosis: a cross-sectional study with matching","volume":"29","author":"Floreani","year":"1997","journal-title":"Ital J Gastroenterol Hepatol"},{"key":"2025082710264122000_12.5.e227316.7","doi-asserted-by":"crossref","first-page":"1320","DOI":"10.1111\/j.1440-1746.2012.07114.x","article-title":"Prevalence and associated factors with esophageal varices in early primary biliary cirrhosis","volume":"27","author":"Ikeda","year":"2012","journal-title":"J Gastroenterol Hepatol"},{"key":"2025082710264122000_12.5.e227316.8","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.1971.00310210148022"},{"key":"2025082710264122000_12.5.e227316.9","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9343(82)90802-6"},{"key":"2025082710264122000_12.5.e227316.10","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2008.01.014"},{"key":"2025082710264122000_12.5.e227316.11","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.1971.00310170168027"},{"key":"2025082710264122000_12.5.e227316.12","doi-asserted-by":"crossref","first-page":"2129","DOI":"10.1093\/ajcn\/32.10.2129","article-title":"Geophagia in rural Mississippi: environmental and cultural contexts and nutritional implications","volume":"32","author":"Vermeer","year":"1979","journal-title":"Am J Clin Nutr"},{"key":"2025082710264122000_12.5.e227316.13","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1111\/j.1365-2141.1976.tb00204.x","article-title":"Pica: a compulsion caused by iron deficiency","volume":"34","author":"Crosby","year":"1976","journal-title":"Br J Haematol"},{"key":"2025082710264122000_12.5.e227316.14","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2326-10-9"},{"key":"2025082710264122000_12.5.e227316.15","first-page":"8","article-title":"Nodular hyperplasia of the liver in primary biliary cirrhosis of early histological stages","volume":"82","author":"Nakanuma","year":"1987","journal-title":"Am J Gastroenterol"},{"key":"2025082710264122000_12.5.e227316.16","doi-asserted-by":"publisher","DOI":"10.1016\/j.jada.2004.06.026"},{"key":"2025082710264122000_12.5.e227316.17","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199812103392408"},{"key":"2025082710264122000_12.5.e227316.18","unstructured":"Bhatia M , Srivastava S , Sharma S . 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