Abstract
IntroductionGastric pharmacobezoars are a rare entity that can induce mechanical gastric outlet obstructions and sometimes prolong toxic pharmacological effects. Certain medications, such as sustained-release forms, contain cellulose derivatives that may contribute to the adhesion between pills and lead to the creation of an aggregate resulting in a pharmacobezoar. Case reports are rare, and official guidelines are needed to help medical teams choose proper treatment options.Case presentationOur patient was a 40-year-old Caucasian woman with borderline personality disorder and active suicidal thoughts who was found unconscious after a massive drug consumption of slow-release clomipramine, lorazepam, and domperidone. On her arrival in the emergency room, endotracheal intubation was preformed to protect her airway, and a chest x-ray revealed multiple coffee grain-sized opaque masses in the stomach. She was treated with activated charcoal followed by two endoscopic gastric decontaminations 12 h apart in order to extract a massive gastric pharmacobezoar by manual removal of the tablets.ConclusionThis case demonstrates that in the case of a massive drug consumption, a pharmacobezoar should be suspected, particularly when cellulose-coated pills are ingested. Severe poisoning due to delayed drug release from the gastric aggregate is a potential complication. Detection by x-ray is crucial, and treatment is centered on removal of the aggregate. The technique of decontamination varies among experts, and no formal recommendations exist to date. It seems reasonable that endoscopic evaluation should be performed in order to determine the appropriate technique of decontamination. Care should be patient-oriented and take into account the clinical presentation and any organ failure, and it should not be determined solely by the suspected medication ingested. Thus, serum levels are not sufficient to guide management of tricyclic antidepressant intoxication.
Highlights
Gastric pharmacobezoars are a rare entity that can induce mechanical gastric outlet obstructions and sometimes prolong toxic pharmacological effects
It is difficult to know when to suspect a pharmacobezoar, but they should always be considered in cases of massive drug consumption
We discuss the proper management of multidrug gastric pharmacobezoars, because they are a rare entity and no formal guidelines exist on how to deal with them
Summary
Our patient was admitted for a drug overdose of slow-release clomipramine, lorazepam, and domperidone resulting in a gastric pharmacobezoar, and she was treated by AC and endoscopic gastric decontamination. In any case of drug overdose, a pharmacobezoar should be suspected, especially when cellulose-coated pills are ingested. Serum levels are not useful to guide management of TCA intoxication because they correlate poorly with clinical effects. They do not help to predict toxicity, even if high serum levels are usually associated with severe toxicity. In light of the wide variety of drugs often implicated in drug overdoses, our patient’s case demonstrates why patient-oriented care should not be based solely on the pharmacological properties of the individual substances.
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