1755 A Case of Xylophagia

Abstract

INTRODUCTION: To describe a case of xylophagia with esophageal obstruction. CASE DESCRIPTION/METHODS: A 59-year-old female with prior medical history of hypertension, depression and PTSD presented with a sensation of mid retrosternal dysphagia and sialorrhea, which began during a meal consisting of eggs and toast. Prior surgical history was significant for prior sleeve gastrectomy. Upon her presentation, the patient noted that there was a several year history of chronic watery diarrhea for which she underwent extensive evaluation at an outside institution. The etiology of her diarrhea remained unclear and multiple empiric medication trials were unsuccessful. A friend of the patient suggested that she might try ingesting small amounts of toilet paper each day to solidify the stool. The patient began this practice several months prior to her presentation to the ED. The patient corroborated that by ingesting a small amount of toilet paper each day, her diarrhea had completely resolved. Aside from sialorrhea, her physical examination was unremarkable. The patient underwent urgent upper GI endoscopy under general anesthesia with endotracheal intubation. The mid and distal esophagus were found to be obstructed with a large amount of fluffy, soft toilet paper (Figure 1). The obstruction was painstakingly relieved by use of rat-tooth forceps and a polyp retrieval net. After nearly 2 hours of endoscopic manipulation, the esophageal obstruction was completely relieved and the duodenum was able to be intubated, with there being only scant amounts of residual toilet paper within the gastric sleeve and proximal duodenum. Post-procedure, the patient was able to ingest liquids and small amounts of solids without difficulty. After psychiatric consultation, the patient was discharged. It was strongly advocated by both the gastroenterology and psychiatric teams, that the patient curtail her habit of xylophagia. DISCUSSION: Xylophagia is a form of pica, involving the ingestion of items made of wood (such as paper, pencils, tree bark). Our patient endorsed commencing her habit of xylophagia in an effort to improve her chronic diarrheal disorder. It was suspected that her underlying psychiatric disease, prior bariatric surgery and willingness to accept another's ill–advised recommendation–all conspired to produce this unusual clinical presentation.