Endoscopic management of intragastric balloon related gastric outlet obstruction: A case report and review of literature

Introduction: Intragastric balloons (IGB) are a safe and effective endoscopic weight loss procedure that has recently been approved for use in the U.S. The Manhattan VA initiated the first bariatric endoscopy program in the country, which works in conjunction with the MOVE! program. We report an interesting case of an obese man with dramatic weight loss and obstructive symptoms after IGB. Case report: Patient is a 45-year-old veteran with BMI of 38 kg/m2, hypertension, and obstructive sleep apnea, who presented for IGB. Physical exam and labs were unremarkable, with initial weight of 233 lbs. An Orbera IGB (Apollo Endosurgery, Austin, TX) was implanted and filled with 650 mL of saline mixed with methylene blue. At 4 months after implantation, the patient had lost an impressive 46 lbs, with active participation in the MOVE! program. At 4 months, he presented with new-onset nausea and vomiting. He denied abdominal pain, or changes in color of stool and urine. Initial abdominal x-ray(AXR) was unremarkable (Fig. 2a). The patient improved temporarily with dietary changes and anti-emetics, but vomiting after solid meals resumed and he was admitted. On admission, his weight was 169 lbs, with K of 3.1 mEq/L, BUN 32, creatinine of 2.0, normal liver tests and lipase. Hyperinflation of balloon, small bowel obstruction, gastric ulceration and gastroparesis were considered. Repeat AXR showed air-fluid levels (Fig. 2b). Upper endoscopy revealed intact freely movable IGB, located in antrum. IGB was removed, and the patient's symptoms resolved. Four months later, the patient has maintained the weight loss, with weight of 174 lbs (BMI 27 kg/m2) and a total excess weight loss of 68%.Figure: Abdominal x-rays 4 months after IGB placement revealed intact balloon (arrows) with no deflation or migration. Fig. 2b. Air-fluid level on hospital admission, 5 months after balloon implantation.Discussion: We present a patient with BMI of 38 kg/m2 status post IGB therapy with 59-lb total weight loss, later complicated by persistent gastric outlet obstructive symptoms with no evidence of mechanical obstruction.This functional dynamic gastric outlet obstruction may be attributed to the patient's sudden weight loss, especially since typical rate of weight loss after IGB is lower. The patient had no diabetes history, underlying infiltrative process, or medications use that could explain the functional gastroparesis. This study highlights an unexpected phenomenon that physicians should be aware of when monitoring effects of acute weight loss and consider in the presentation of late nausea and vomiting (after 3 months of implantation) in patients with IGB.Figure: Image of endoscopic intragastric balloon placed in gastric fundus and inflated with 650 mL of saline.Figure: BMI trend over 9 months, including time of IGB placement, hospitalization with IGB removal, and four-month follow-up after extraction.

INTRODUCTION: Intragastric balloons (IGB) are commonly being used for the treatment of obesity, with increasing data confirming their effectiveness. While usually well tolerated with rare adverse events, IGBs have been associated with complications including visceral perforation, pancreatitis and bowel obstruction. IGB hyperinflation, which occurs due to an abnormal accumulation of gas within IGB is rare. We present a case of a patient with abdominal pain and vomiting after recent IGB placement, found to have a palpable abdominal mass. CASE DESCRIPTION/METHODS: A 35-year-old female with class II obesity (BMI: 33 kg/m2) and recently placed adjustable IGB in the Dominican Republic presented to our emergency department with abdominal fullness, vomiting and inability to keep food down. The IGB had been placed for two months with reported 30 lbs weight loss. She denied fevers, dysphagia, hematemesis, melena or altered bowel movements. She was afebrile with normal vital signs. Physical examination revealed a palpable round-like mass in her epigastric region with tenderness to palpation. Laboratory workup, including complete blood count, basic metabolic panel, liver function tests and lipase were normal. CT scan of the abdomen and pelvis revealed a gas-filled hyperinflated IGB within the distal portion of the stomach with dilation proximally representing possible gastric outlet obstruction. There was no evidence of perforation or pneumatosis intestinalis [Figure 1a–c]. Due to her symptoms, and the patient’s wishes to have the balloon removed, endoscopy was performed. Endoscopy revealed a hyperinflated, adjustable IGB occupying two thirds of the gastric body and obstructing the gastric antrum. The balloon appeared mottled suggesting fungal colonization from the outside with food debris. Attention was then placed on balloon removal. Successful removal of 500cc of blue-colored fluid mixed with air was performed resulting in IGB deflation and subsequent retrieval. The patient did well with resolved symptoms and was discharged the next day. DISCUSSION: Intragastric balloon hyperinflation should be recognized as a possible complication of IGB placement and may be due to balloon permeability or gas-producing anaerobic bacteria. Patients usually present with nausea, vomiting and inability to tolerate oral intake and if left untreated can result in dire consequences. Imaging may assist with diagnosis. Treatment involves endoscopic IGB removal. In cases of adjustable IGB, deflation and fluid exchange can be considered.

Intestinal occlusion as unusual complication of new intragastric balloon Spatz Adjustable Balloon system for treatment of morbid obesity

INTRODUCTION: Intragastric balloons (IGB) function as an artificial bezoar and delay gastric emptying by increasing wall strain and contributing to feelings of satiety. 25% of patients who undergo IGB placement will experience complications, with nausea and vomiting as the most common (8.6%), and obstruction within the digestive tract as a much rarer cause (0.8%). Here we report gastric outlet obstruction (GOO) as a rare complication of IGBs. CASE DESCRIPTION/METHODS: A 67-year-old female with hypothyroidism and major depressive disorder presented with 5 days of profound nausea and vomiting. Prior to admission, the patient underwent gastric balloon placement and after the procedure, the patient was unable to tolerate both solid food and liquids. The patient denied any abdominal pain and her last bowel movement was 2 days prior to admission. Lab work revealed severe hypokalemia (2.6 mmol/L) and hypomagnesemia (< 0.2 mg/dL). CT imaging of the abdomen and pelvis revealed an 11-cm gastric balloon within the distal stomach without signs of bowel obstruction (image 1). The patient immediately underwent esophagogastroduodenoscopy, which revealed the IGB obstructing a large food bolus (image 2). The IGB was subsequently deflated and removed. The patient was discharged home after electrolyte repletion and diet toleration. DISCUSSION: Traditionally, the IGB is a silicone balloon filled with saline that is adjustable in size, safe, and significantly effective in weight loss. Almost half of all gastric balloons are removed early. Indications for gastric balloon removal include severe symptom intolerance, balloon deflation, digestive tract obstruction, and concern for gastric ulcer/perforation. Its risks for serious complications should not be overlooked, as digestive tract obstruction from displaced or deflated balloons may lead to gastric perforation or even death. There is debate regarding the preference for type of fluid or air medium in IGBs. The recently implemented air-filled IGB has also been effective in significant weight loss reduction with lower rates of nausea, vomiting and bowel obstruction compared to fluid-filled IGBs. In this case, this was the second fluid-filled IGB the patient had placed and removed. A different type of IGB could have been considered. With new emerging technology in both endoscopic technique and balloon durability, new studies will need to examine the continued safety and efficacy of gastric balloons in obesity management.Figure 1.: Image 1. CT chest with oral contrast, depicting large saline filled gastric balloon.Figure 2.: Image 2. Left: IGB obstructing antrum from prior EGD; Right: IGB obstructing antrum with food bolus.

The marble test for gastric outlet obstruction in chronic granulomatous disease

Bariatric endoscopic antral myotomy: first-in-human proof of concept of a novel therapeutic method to delay gastric emptying and induce weight loss

75-Year-Old Man With Abdominal Pain and Reflux

Airway obstruction due to a Sengstaken-Blakemore tube.

Intragastric balloon therapy for weight loss has been recently reintroduced in the United States as a treatment option for patients with obesity. Both the ReShape Integrated Dual Balloon System and the Orbera Intragastric Balloon System were approved for use by the FDA last summer based on randomized trials which demonstrated weight loss benefit over control groups even 6 months after device removal. The currently approved intragastric balloons overcome the issues of the first generation of intragastric balloons, including a lack of weight loss in randomized sham controlled trials (1). The mechanism of action of intragastric balloon therapy has also been studied. Research has demonstrated that at least 400 mL of volume is needed in an intragastric balloon in order to produce weight loss over control (2). The ineffective Garren-Edwards Bubble only had a volume of 220 mL, suggesting that at least one mechanism for weight loss with the intragastric balloon is occupation of space in the stomach. However, evidence of other mechanisms causing weight loss with intragastric balloon therapy were also considered early on. Patients have significant retention of food in the stomach on intragastric balloon removal and are instructed to consume a liquid diet for several days before removal in order to reduce the risk of aspiration. This is similar to what is seen in patients with gastroparesis, a disease of delayed gastric emptying resulting in weight loss (3); and the finding led several investigators to measure gastric emptying in patients before, during, and after intragastric balloon implantation in small uncontrolled studies (4, 5). These demonstrated that there was a significant increase in gastric retention of solids with intragastric balloons implanted in the stomach but were limited by the lack of a control group. The study by Gómez et al. (6) in this issue of Obesity reports the results of intragastric balloon therapy on gastric emptying in a randomized controlled trial. Not only did intragastric balloon therapy result in significantly increased gastric retention of food, but the amount of gastric retention correlated with weight loss both at balloon removal and 6 months after balloon removal and was not seen in patients in the control group. This suggests that the physiologic changes which result in delayed gastric emptying during intragastric balloon implantation continue to exert some effect even after the device is removed. The results of this study may also help to explain the weight maintenance that is seen in the first 6 months after intragastric balloon removal (7) and is in contrast to the weight gain that is seen immediately after cessation of obesity medications (8). The mechanisms behind intragastric balloon-induced delayed gastric emptying are unclear. Emptying of gastric contents into the small bowel is a complex process that involves coordination of multiple organs and signaling from mechanical, chemical, and neurohormonal stimuli. Moreover, delayed gastric emptying did not explain all of the variance in weight loss with intragastric balloon therapy. Further research is needed to better understand the mechanisms responsible for delayed gastric emptying in patients treated with intragastric balloon therapy and other mechanisms that are also involved in intragastric balloon-induced weight loss. As with all obesity therapies, our ultimate goal is to understand how intragastric balloon therapy works to both identify patients who will be most likely to respond to the therapy before placing the intragastric balloon and to optimize therapy with the intragastric balloon in place.

Intragastric Balloon in the Emergency Department: An Unusual Cause of Gastric Outlet Obstruction

Intragastric balloons are used as a temporary restrictive method in obesity to induce weight loss. They are typically recommended when patients have mild obesity and have failed traditional first line treatments of diet, exercise and behaviour modification. We report a case of a 45-year-old female who presented with nausea, vomiting and abdominal pain two weeks following an uncomplicated insertion of an intragastric balloon. Following investigation, she was found to have a gastric outlet obstruction which required endoscopic removal of the balloon. While a rare occurrence, gastric outlet obstruction as seen in this case, highlights the importance of early recognition in order to proceed with swift diagnosis and intervention in order to prevent significant morbidity such as ischaemia and perforation.

Introduction Obesity is a public health priority in the UK. Bariatric endoscopy falls between lifestyle interventions and surgical options, but few centres offer this service. Studies reporting weight loss outcomes and adverse events in patients receiving the intragastric balloon (IGB) are heterogeneous in design and location (1). We report outcomes from an IGB service at a London teaching hospital. Method We conducted a retrospective analysis of consecutive IGB insertions between 01/09/2014 and 31/08/2016, using information held in the Electronic Patient Record. The primary outcome was weight loss at IGB removal, calculated in kilograms (kg). Secondary outcomes were premature removal (defined as IGB removal before 175 days) and emergency treatment (defined as emergency department attendance or hospital admission related to IGB). The paired t-test was used to compare weight before and after IGB. Univariable regression analyses were used to explore patient factors associated with each outcome. Complete case analyses were carried out where data were missing. Stata version 13.1 was used for all statistical analyses. Results There were 172 IGB insertions in 127 patients; mean age 46.8 years, 73.3% female, and mean baseline weight 110 kg. 41% had previous experience of IGBs. Most were performed on a day case basis. Median time to IGB removal was 182 days (interquartile range (IQR) 126 to 196). Mean weight loss per IGB was 8.9 kg (95% CI 7.4 to 10.4), range 32.2 kg weight loss to 11.6 kg weight gain. 62 (36.1%) IGBs were removed prematurely and 48 (27.9%) patients required emergency treatment. Of these, 47 (97.9%) had nausea or vomiting, 20 (41.7%) abdominal pain, 5 (10.4%) haematemesis or melaena, and 13 (27.1%) hypokalaemia. Median time to emergency treatment was 7 days from IGB insertion (IQR 2 to 23), and median length of stay was 2 days for emergency admissions (IQR 1 to 4). 31 (64.6%) underwent inpatient IGB removal. On average, for every 1 kg increase in baseline weight, weight loss increased by 0.11 kg (95% CI 0.03 to 0.18), and there was a 2% reduction in the odds of premature removal (OR 0.98, 95% CI 0.97 to 1). Patients with previous experience of IGBs lost 6.6 kg less than those naive to IGBs (95% CI −9.5 to −3.71) and had a 64% increase in the odds of premature removal (OR 1.64, 95% CI 0.87 to 3.09). Age and sex did not affect any outcomes, and no studied factor affected emergency treatment. Conclusion The IGB offers an interventional weight loss alternative to patients who do not want, or who are not fit for, bariatric surgery. The more overweight individuals have better outcomes. Further research is required to identify factors associated with adverse events following IGB insertion. Reference . Yorke E, Switzer NJ, Reso A, et al. Intragastric Balloon for Management of Severe Obesity: a Systematic Review. Obesity Surgery. 2016 Disclosure of Interest None Declared

Gastric outlet obstruction can be a dangerous complication of intragastric balloons, as it can result in severe metabolic alkalosis. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers. Intragastric balloons for weight loss have decreased in frequency in the United States. However, they are still frequent in low- and middle-income countries. Severe complications occur in less than 3% of patients who undergo this procedure. Herein, we present a case of gastric outlet obstruction, severe metabolic alkalosis, and refeeding syndrome in a patient returning from the Dominican Republic. She presented with 2 weeks of emesis and obstipation, followed by a pre-syncope and altered mental status. An intragastric mass was observed on computerized tomography, which was characterized as an intragastric balloon and retrieved endoscopically. All metabolic derangements were corrected, and the patient improved without sequelae. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers.

The intragastric balloon (IGB) acts as a restrictive procedure with acceptable short-term weight loss outcomes and a low incidence of major complications. This systematic review and meta-analysis aimed to assess whether preoperative insertion of an IGB can reduce perioperative complications and improve weight loss outcomes following metabolic bariatric surgery (MBS). PubMed, Embase, Scopus, and Web of Science databases were searched using relevant keywords to include studies on IGB as a bridge before MBS. The main outcome of this study was to compare the weight loss results and complications after MBS between the IGB group and the control group. For the meta-analysis of variables with severe and non-severe heterogeneity, random-effects and fixed-effects meta-analyses were used, respectively. Eleven articles were included. The IGB and control groups included 318 and 501 patients, respectively. The pooled random-effects analysis of six studies showed that preoperative IGB insertion resulted in a body mass index (BMI) loss of 7.45kg/m2 over a mean follow-up of 6.14months. The major complication rate for IGB was 5%. The mean BMI change after MBS between the IGB and control groups was not significantly different after 15.06months (mean difference - 4.08, p = 0.07). Additionally, a fixed-effects analysis of ten studies found no significant difference in post-MBS complication rates between the IGB and control groups (OR 0.66, p = 0.12). Even though using IGB as a bridging approach to subsequent MBS can result in significant reductions in preoperative BMI, this weight loss does not appear to positively impact the overall outcomes of MBS in patients inthe long term.

70-Year-Old Man With Chronic Nausea and Vomiting