Intragastric Balloon for Obesity Causing Gastric Outlet Obstruction

Abstract

FigurePurpose: Intragastric balloons are indicated for treatment of moderately obese patients. Major complications include immediate gastric outlet obstruction, spontaneous deflation causing obstruction, and gastric perforation. We report a case of delayed gastric outlet obstruction. A 59 yo female presented with nausea, vomiting and abdominal pain for 5 days. The patient had an intragastric balloon (BioEnterics Intragastric Balloon – BIB, INAMED Health, Santa Barbara, CA) placed 9 weeks prior in Mexico having lost 30 lbs with a BMI of 35 kg/m2. Past history included GERD and laparoscpic cholecystectomy. Her vital signs were stable. Her RUQ and epigastrum were firm and tender. Serologies showed: Na 137, K 2.6, Cl of 91, CO2 35, glucose 127, BUN 18, and creatinine 1.4. Upper GI series showed positional barium passage (Fig. 1).[figure1]Endoscopy, using Olympus GIF 140 (Olympus Corp), showed a fundal balloon occluding the lumen (Fig. 2). A scleroneedle and a rat tooth forcep were used to puncture the balloon and drain its contents. The endoscope was reinserted with an overtube (Bard Endoscopic Overtube). A jumbo snare was used to impact the balloon into the overtube at 10 cm. All were removed in unison with anesthesia on standby.[figure2]The following day, the patient complained of a sore throat and chest pain and had a temperature of 38.8. The leukocyte count was 11.93 K/uL (normal 4.8–10.8 K/uL). CT scan of the neck and chest showed a small amount of air in the paraesophageal space and mediastinum.FigureThe patient was treated with piperacillin/tazobactam 4.5 grams q8° IV, metronidazole 500 mg q6° IV, gentamicin 240 mg IV daily and made NPO. She was discharged 10 days later. In conclusion, a delayed gastric outlet obstruction occured after intra-gastric balloon placement. Endoscopic balloon removal with overtube assistance was complicated by a small esophageal perforation, managed conservatively.