All Tied Up: Not Your Typical Distended Abdomen

Abstract

Question: A 28-year-old woman with a history of iron deficiency anemia and pos-traumatic stress disorder was evaluated in the emergency department for 2 weeks of intermittent abdominal discomfort, nausea, and vomiting. Physical examination revealed a young woman with a hard distended abdomen that was diffusely tender to palpation. Lab oratory tests were significant for a low hemoglobin (9.4 gm/dL), low mean corpuscular volume (75 fL), and low ferritin (7). Her white blood cell volume (7.9 × 10³ mL) and lactic acid (1.3 mEq/L) were normal. A pregnancy test was negative and an abdominal computed tomography scan was performed (Figure A). What is the diagnosis and what is the next best step in management? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. This patient has pica and had been consistently ingesting elastic hair ties for the past 5 years—since the birth of her child. The computed tomography scan (Figure A) shows her stomach to be markedly distended with ingested material (innumerable, thin, linear, radiodense structures) located throughout the stomach and proximal duodenum. An upper endoscopy with monitored anesthesia care was subsequently performed and confirmed the presence of ingested hair ties throughout the gastric cavity (Figure B). The ties had coalesced into several large, tangled, hardened masses consistent with gastric bezoars. An overtube was placed and the foreign bodies were removed in sequential fashion with a rat-tooth forceps and cold snare. After partial removal, a 1.4-cm nonbleeding crater ulcer was found at the incisura (Figure C) and a large number of ties were extricated from the pyloric sphincter. In total, 172 individual bands were removed (Figure D). The patient recovered without event, and hematology and psychiatry services were consulted. Pica refers to repeated consumption of nonfood substances and has been associated with both iron deficiency anemia and pregnancy, although the underlying mechanism is not well-understood.1Al Nasser Y. Muco E. Alsaad A.J. Pica.in: StatPearls. Treasure. StatPearls Publishing, Island, FL2021Google Scholar A majority of ingested objects pass without the need for intervention, although the need seems to be higher with intentional ingestions.2Ikenberry S.O. Jue T.L. Anderson M.A. et al.ASGE Standards of Practice CommitteeManagement of ingested foreign bodies and food impactions.Gastrointest Endosc. 2011; 73: 1085-1091Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar A gastric bezoar specifically refers to a collection of indigestible material accumulating in the stomach.3Pfau P.R. Benson M. Foreign bodies, bezoars, and caustic ingestions.in: Sleisenger and Fordtran’s gastrointestinal and liver disease- 2 volume set: pathophysiology, diagnosis, management. 11th ed. Elsevier, New York2020: 399-410Google Scholar These generally occur in the setting of poor gastric emptying, with vegetable matter (phytobezoar), hair (trichobezoar), and medications (pharmacobezoars) being the most common.3Pfau P.R. Benson M. Foreign bodies, bezoars, and caustic ingestions.in: Sleisenger and Fordtran’s gastrointestinal and liver disease- 2 volume set: pathophysiology, diagnosis, management. 11th ed. Elsevier, New York2020: 399-410Google Scholar Clinical manifestations include anorexia, nausea, vomiting, and early satiety. Gastric ulceration secondary to pressure necrosis and mechanical obstruction secondary to accumulation in the small intestine can occur.3Pfau P.R. Benson M. Foreign bodies, bezoars, and caustic ingestions.in: Sleisenger and Fordtran’s gastrointestinal and liver disease- 2 volume set: pathophysiology, diagnosis, management. 11th ed. Elsevier, New York2020: 399-410Google Scholar Urgent endoscopy or surgical intervention are indicated in patients with objects causing gastrointestinal tract obstruction.2Ikenberry S.O. Jue T.L. Anderson M.A. et al.ASGE Standards of Practice CommitteeManagement of ingested foreign bodies and food impactions.Gastrointest Endosc. 2011; 73: 1085-1091Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar An overtube facilitates the sequential removal of foreign bodies with protection of the airway. If endoscopic therapy is unsuccessful or complications such as perforation arise, surgical intervention may be required.3Pfau P.R. Benson M. Foreign bodies, bezoars, and caustic ingestions.in: Sleisenger and Fordtran’s gastrointestinal and liver disease- 2 volume set: pathophysiology, diagnosis, management. 11th ed. Elsevier, New York2020: 399-410Google Scholar