An Unusual Case of a Gastric Foreign Body

Abstract

Question: A 49-year-old man who had undergone a Billroth I partial gastrectomy for early gastric cancer 5 years earlier presented with postprandial nausea and upper abdominal discomfort over a 6-month period. The patient had been under surveillance for 5 years since his operation and no recurrence had been detected. Because of chronic constipation, he had regularly taken a laxative for approximately 20 years. Physical examination and routine laboratory data were unremarkable. Upper endoscopy revealed an ovoid, brownish foreign body with a honeycomb-like appearance in the stomach remnant (Figure A, B). This was removed endoscopically and found to be elastic and soft (Figure C), measuring 30 × 18 mm. What is this foreign body? Look on page 1500 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The foreign body was endoscopically diagnosed as a bezoar, and then removed with a capture net (Figure D). The cut surface had a honeycomb appearance, similar to the outer surface (Figure E). Fourier transformed infrared spectroscopy revealed that the spectrum of the bezoar closely fit that of the laxative he had taken, Satolax (Figure F). Satolax is primarily composed of plantago ovate, also known as psyllium, which has the strong ability to absorb and retain liquids. Psyllium is widely used as a bulk-forming laxative and goes by the trade names including Isabgol, Perdiem, and Serutan. Recently, psyllium has been reported to be effective against many medical problems, including ulcerative colitis, hyperlipidemia, and diabetes mellitus.1Plantago ovata (psyllium).Altern Med Rev. 2002; 7: 155-159PubMed Google Scholar However, some side effects have been reported, the most fatal being anaphylaxis.1Plantago ovata (psyllium).Altern Med Rev. 2002; 7: 155-159PubMed Google Scholar Gastrointestinal obstruction caused by a bezoar is extremely rare. We found only 23 reported cases. The esophagus was the most frequently involved organ (70.8%), followed by the colon (8.3%), the small bowel (8.3%), and the stomach (8.3%). Suggested risk factors include insufficient water intake, medication overdose, strictures, and functional disorders. In our case, decreased gastric output in the setting of a gastrectomy may have contributed. Diagnosis of a bezoar can often be made by history alone. In our case, a Fourier transformed infrared study clearly demonstrated that the bezoar consisted of a psyllium-based laxative. Endoscopy showed characteristic features as described by other reports of similar cases.2Angueira C. Kadakia S. Esophageal and duodenal bezoars from Perdiem.Gastrointest Endosc. 1993; 39: 110-111Abstract Full Text PDF PubMed Scopus (12) Google Scholar, 3Pérez-Piqueras J. Silva C. Jaqueti J. et al.Endoscopic diagnosis and treatment of an esophageal bezoar resulting from bulk laxative ingestion.Endoscopy. 1994; 26: 710Crossref PubMed Scopus (14) Google Scholar Angueira and Kadakia2Angueira C. Kadakia S. Esophageal and duodenal bezoars from Perdiem.Gastrointest Endosc. 1993; 39: 110-111Abstract Full Text PDF PubMed Scopus (12) Google Scholar described a psyllium bezoar as looking like a “Fabergé egg.” Treatment of psyllium bezoar is mainly endoscopic division and removal with forceps or snare. In our case, capture net was effective and easily employed.