Successful Emergency Endoscopic Extraction of Gastric Outlet Obstruction Due to Bezoar with Gastric Pneumatosis

Abstract

Introduction: Gastric pneumatosis (GP) is generally categorized as either emphysematous gastritis (EG) or gastric emphysema (GE). The former has a more ominous presentation, usually requiring a gastrectomy in order to remove necrotic tissue. The breaking and removal of a gastric bezoar causing gastric outlet obstruction (GOO) and subsequent GP is extremely difficult. Here, we present a case of a safe and successful removal of a bezoar with radiologic findings consistent with GP. Presentation Of Case: An 89-year-old man with a history of type 2 diabetes mellitus (DM) presented to our emergency room with a 2-day history of upper abdominal pain, nausea and vomiting. CT scan of the abdomen showed a dilated stomach with significant fluid collection, GOO and GP due to a 42x40 mm mass composed of fat and air densities. Emergency endoscopy revealed two gastric bezoars, one of which was incarcerated in the pyloric region. We used various endoscopic devices to successfully break and remove the bezoar endoscopically. Follow-up endoscopy confirmed that the gastric bezoar had been completely removed.Figure 1Figure 2Figure 3Discussion: Gastric bezoars presenting with GOO are generally too large to extract and too hard to break.There are several reports of bezoars which required surgical removal or dissolution therapy using Coca-Cola.On the other hand, reports of successful endoscopic removal of bezoars presenting with GOO and GP are extremely scarce.In this case, the size of the bezoar (over 40mm) made it necessary to break it using endoscopic snares, forceps and nets. Patient was able to avoid surgery through repeated endoscopic procedures.History of gastrectomy, old age, and type 2 DM are risk factors of phytobezoars which are composed of undigested food.Endoscopic treatment is preferable to surgery not only because it is less invasive, but also because of the possibility of recurrence of post-gastrectomy phytobezoars.GP in this case was believed to be GE, as 1) endoscopy findings showed several gastric ulcers due to mucosal injury arising from intraluminal high pressure resulting from obstruction, 2) the patient was in no apparent distress and 3) CT scan did not show evidence of ischemia. We believe that endoscopic therapy should be attempted before surgery in cases of GE. Conclusion: Endoscopic treatment may be a safe and viable option for the extraction of gastric bezoars presenting with GOO and GP when the patient's condition is stable and there is no evidence of ischemia.