1748 Blood Bezoar: A Rare Complication of Achalasia

Abstract

INTRODUCTION: Bezoars are retained concretions of indigestible foreign material that accumulate and conglomerate in any part of the GI tract but rarely in the esophagus. Only a few patients with achalasia have been reported to develop esophageal bezoars. CASE DESCRIPTION/METHODS: 76-year-old-man with history of atrial fibrillation on anticoagulation and achalasia s/p Heller myotomy in 1990, endoscopic dilation in 2007 and botox injection in 2015 who presented due to hematemesis after an episode of food binge. An upper endoscopy was performed with evidence of a severely dilated esophagus and presence of a bulky, cylindrical, foreign body composed of digested food and coagulated blood resembling a large blood sausage. The foreign body was removed through upper esophageal sphincter in piecemeal with a polypectomy snare and roth net using an overtube for airway protection. Two endoscopic procedures were necessary to completely remove the huge cylindrical esophageal bezoar. DISCUSSION: Bezoars are retained concretions of indigestible foreign material that accumulate and conglomerate in any part of the GI tract but rarely in the esophagus. They may occur due to ingestion of undigestible material or in patients with impairment in the grinding mechanism and the interdigestive migrating motor complex. Achalasia is an uncommon disorder resulting from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall, leading to failure of relaxation of the lower esophageal sphincter accompanied by a loss of peristalsis in the distal esophagus. Dysphagia for solids and liquids and regurgitation of undigested food are the most frequent symptoms, however patients may also present with chest pain, heartburn, and difficulty belching. Only a few patients with achalasia have been reported to develop esophageal bezoars. In such cases, patients may be asymptomatic for years, or present with symptoms like abdominal pain, nausea, vomiting or serious complications like outlet obstruction, perforation and hematemesis. Upper endoscopy is regarded as the mainstay modality for the diagnosis and treatment of esophageal bezoars. In difficult cases, step by step management with N-acetylcysteine and gastrografrin spraying has been reported. Surgery should be reserved for select patients with bezoars if chemical dissolution and endoscopic fragmentation cannot be performed or fail, as well as for patients with significant complications such as obstruction and severe bleeding.