Life-Threatening Gastric Outlet Obstruction after Placement of an Intra-gastric Balloon for Weight Loss

Abstract

A 34 year-old female underwent an Orbera intragastric balloon placement for weight loss complicated by post-procedure abdominal pain, nausea and vomiting. Two days later, she was admitted to an outside hospital. CT Imaging was concerning for gastric outlet obstruction due to the balloon with a massively dilated stomach. She became increasingly tachypneic and hypoxic requiring elective intubation, NG tube placement and endoscopic removal of the balloon. Her respiratory status declined rapidly with fever, increasing oxygen requirements and leukocytosis. She was transferred to a tertiary care center for ECMO for likely aspiration pneumonia complicated by ARDS. The patient's course was complicated by upper gastrointestinal bleeding requiring EGD notable for blood in the stomach and devitalized gastric body tissue with ulceration, eschar and edema. Gastric balloon devices have been used for over 20 years to assist with weight loss. Recent changes in balloon design have increased the frequency of their usage. Balloons are placed endoscopically and are filled with either saline or air (400-750 mL) and are designed to function as space-occupying devices within the gastric lumen to restrict the amount of food a patient can eat. The advantage of this procedure is its lower risk and cost and is less invasive when compared to surgery. Weight loss has been documented at 31-46% loss of excess weight in 3-6 months. The balloons are typically left for 6-12 months for maximal effect. A meta-analysis of 3600 patients who received an Orbera balloon demonstrated only 2 fatalities and both occurred in patients with prior gastric surgery. Reported adverse events included nausea, vomiting, bowel obstruction (0.8%), and gastric perforation (0.1%). The balloon is filled with 10 mL of methylene blue so that in event of balloon leakage, the urine turns blue indicating them to seek medical attention. In our case, the balloon appeared to migrate and caused a pyloric obstruction. The patient also suffered from gastric ulcerations causing bleeding and gastric hematoma likely due to pressure necrosis from the obstructed balloon. The course was further complicated by an aspiration event with resultant ARDS requiring ECMO stabilization for 35 days before being transitioned to lower intensity care. Some gastric discomfort, nausea and vomiting can be expected after placement of the balloon, however, persistent symptoms demand prompt evaluation and management.Figure 1