Large Bezoar Research Articles

Surgical Treatment of Gastric Trichobezoar in a Patient with Trichophagia: A Case Report

There are multiple causes of intestinal obstruction of mechanical origin, being a rare entity in young patients without underlying organic pathology or previous surgical interventions. The presence of a large bezoar in the gastric cavity as the origin of the obstructive condition is unusual, particularly that of trichobezoars, which is why we describe the following case We present a 19-year-old woman with a history of anxiety-depressive syndrome who has had a trichophagia disorder for the last year. Given the diagnosis of gastric sub-occlusive syndrome with diffi culty in ingestion secondary to large gastric bezoar, surgical intervention was decided to resolve the condition surgically

S3689 Unforeseen Postoperative Complication in a Bariatric Patient: The Rare Case of a Large Phytobezoar Causing Gastric Outlet Obstruction

Introduction: Bariatric surgery has become increasingly popular in the treatment of obesity to achieve sustainable weight loss. Despite its numerous benefits, complications can arise due to postoperative gastric hypoacidity and motility disorders. Phytobezoars is an infrequent complication of bariatric surgery that arise from impacted aggregates of indigestible fruit and vegetables. Rarely, bezoars can cause gastric outlet obstruction and/or perforation. The following case highlights the presentation, diagnosis and treatment of phytobezoars and the importance of diet compliance in bariatric patients. Case Description/Methods: A 60-year-old woman with hyperlipidemia was admitted due to progressive epigastric fullness and postprandial emesis of 2 weeks’ duration. Moreover, nausea was constant associated with abdominal bloating and 7-pound weight loss. Pepcid did not alleviate symptoms. She denied fever, chills, chest pain, shortness of breath, diarrhea, constipation, hematochezia nor hematemesis. Her past surgical history was pertinent for sleeve gastrectomy in 2017. She denied toxic habits. Labs were unremarkable except for isolated thrombocytopenia. Physical exam was pertinent for mild epigastric tenderness; no abdominal rigidity nor guarding present. Despite abdominopelvic CT revealing a gastric fundus dilation, an upper GI series was the study that diagnosed a large lobular filling defect compatible with a 7.2 cm phytobezoar.1 Upon questioning, the patient reported that she arrived from a cruise vacation before onset of symptoms. She recalled consuming large amounts of vegetables, nuts and fruits. Initial intervention consisted of papain meat tenderizer to help dissolve bezoar. Nevertheless, symptoms persisted due to oral medication intolerance. Upper endoscopy was performed and phytobezoar was removed with Roth Net retriever. After procedure, patient was able to progressively tolerate diet and was discharge home with resolution of symptoms. Avoidance of excessive high fiber diet was recommended to prevent future bezoar formations (Figure 1). Discussion: The incidence of large phytobezoars has been reported as low as 0.3% in the general population, and therefore, its identification is a diagnostic challenge. Even though most of the patients remain asymptomatic, large bezoars can cause gastric outlet obstruction that could end in perforation if not treated promptly. This case emphasizes the importance of considering phytobezoars as a cause of GI symptoms and the importance of diet education in bariatric patients.Figure 1.: 1. Upper GI series X-ray showing a 7.2 cm phytobezoar causing a large lobular filling defect in the stomach fundus.

S2057 Large Bezoar With Partial Colon Obstruction Secondary to Chronic Opioid Use, Required Surgical Intervention

S2057 Large Bezoar With Partial Colon Obstruction Secondary to Chronic Opioid Use, Required Surgical Intervention

Minimally invasive treatment of duodenal obstruction with acute pancreatitis caused by two large bezoars.

Bezoar without gastrointestinal surgical history occurring simultaneously in the gastric and duodenal lumen is very rare. We report a case of acute pancreatitis due to duodenal obstruction caused by two large bezoars. Two large bezoars were detected in the gastric and duodenal lumen, respectively, on abdominal computed tomography (CT) scan and oesophagogastroduodenoscopy images. Bezoars were crushed and removed using endoscopic devices such as trapezoid basket and lithotripsy handle. After removal of bezoars, blood tests and CT follow-up tests confirmed improvement. In the case of bezoar, which causes duodenal obstruction, it is difficult to administer coke for dissolution, and if it is difficult to perform surgical approach due to old age, an endoscopic treatment using mechanical lithotripsy devices can be an alternative option.

S3177 Combination of Chemical Dissolution and Endoscopic Removal as an Alternative to Surgical Removal of Huge Phytobezoar

Introduction: Bezoars are the collection of undigested or slowly digested materials in the gastrointestinal tract. The phytobezoars are the most common type. Phytobezoars develop rapidly and usually present with gastric outlet obstruction symptoms. Here in, we report a case of giant phytobezoar which responded to chemical dissolution with carbonated fluids (Coca-cola) and cellulase which was later removed by endoscopic procedure. Case Description/Methods: A 65-year-old elderly male with a past medical history of arthritis presented with epigastric pain and vomiting for two months without any significant weight loss. He was found to have cholelithiasis and Cholecystitis on previous admission for similar complaints, for which he underwent laparoscopic cholecystectomy 1 month back. Persistent epigastric pain made us think of other possibilities. On further questioning, he said that he has been ingesting some herbs for arthritis. Subsequently, the patient underwent upper Gastrointestinal endoscopy, which revealed a stony hard, mobile, large bezoar of 9.0 × 10.0 cm. Endoscopic extraction was not possible due to hard consistency and huge size. Chemical dissolution with enzyme cellulase supplements and coca-cola drinks were advised to the patient. Two sequential endoscopies with an interval of 20 days demonstrated the reduced size of the bezoar, and it was successfully removed with the help of a polypectomy snare in piecemeal fashion. The patient remained symptoms free after the removal of the bezoar. Discussion: Gastric bezoars are indigestible foreign material and present with reduced gastric motility. Bezoars may be asymptomatic, but can cause serious complications. Diagnosis is made by imaging or by direct endoscopic visualization. Small soft bezoars can pass the intestinal tract and can be managed medically by inhibiting the gastric acid secretion or neutralizing secreted acid by administering the proteolytic enzymes, cellulase, carbonated fluids given orally or by gastric lavage followed by endoscopic fragmentation. However, large hard bezoars need aggressive surgical management. We treated the giant phytobezoar with chemical dissolution followed by endoscopic removal in piecemeal fashion. This approach has prevented the patient from going through the complications of surgical approach. We recommend that the chemical dissolution can be tried even in giant bezoars before considering a surgical approach. Ours is the first case that demonstrated the response of giant phytobezoar to chemical dissolution.

A68 DISTAL MIGRATION OF A PERCUTANEOUS GASTROJEJUNAL DUODOPA INFUSION TUBE DUE TO BEZOAR FORMATION AT THE JEJUNAL TUBE TIP

Abstract Background Continuous intestinal infusion of levodopa/carbidopa intestinal gel (LCIG) for the treatment of advanced Parkinson’s Disease (PD) leads to less variability in plasma drug levels and improved symptom control. Percutaneous Gastrojejunostomy (PEG-J) tube placement has a high placement success rate; however, delayed tube malfunctions occur in approximately 58% of cases within two years. A rare complication is bezoar formation at the jejunal tube tip. Aims To present a case of bezoar formation at the jejunal tip of a PEG-J tube that caused distal migration of the tube with gastroduodenal ulceration and required surgical extraction. Methods Full chart review was conducted including clinical notes, laboratory results, radiographic imaging, endoscopy reports, and surgical reports. A relevant literature review was conducted. Results A 57-year-old male with severe PD underwent endoscopic guided PEG-J tube insertion for continuous infusion of LCIG; intestinal administration was effective for symptom control. Two years later, he noted that the gastric tube had retracted approximately 15 cm into the stoma without external manipulation of the apparatus. Attempts to externally pull the tube back into position were unsuccessful. The patient underwent Gastroscopy (EGD) with fluoroscopy. Contrast was used to confirm placement of the jejunal tip within the jejunum, but also showed migration of the gastric tip into the duodenum. A gastroscope was used to reposition the gastric tube in the stomach; the jejunal tube was visualized to be under traction. The bumper on the apparatus was re-positioned and external tape was used to further secure the apparatus and prevent migration. A month later the tube had migrated again; repeat EGD showed the jejunal tube to be under traction with some resultant ulceration of the pyloric channel and duodenal bulb where the tube had been pressing against the mucosa. The jejunal tube could not be pulled back and appeared to be fixed distally. A CT scan was obtained to assess for complications and a coiled tip was seen in the proximal jejunum. Surgical extraction of the malfunctioning tube was required. At laparotomy, the coiled tip of the feeding tube was successfully removed via enterotomy. The tube tip had coiled around itself and was encased with food materials, creating a large bezoar that was being pulled distally by peristalsis. The patient subsequently underwent insertion of a new GJ tube for ongoing administration of LCIG and has been doing well since. Conclusions Bezoar formation at the jejunal tip of LCIG PEG-J tubes is a rare complication and can lead to distal migration and traction related gastroduodenal ulceration. Surgical removal may be required. Funding Agencies None

Trichobezoars: a hairy cause of intestinal obstruction

Trichobezoars are an infrequent form of bezoar found in the stomach or intestine, created from ingested hair. Their most frequent location is in the stomach but they may extend through the pylorus into the small bowel. This condition is known as Rapunzel syndrome. Trichobezoar with Rapunzel syndrome is an uncommon diagnosis in children. Authors report 3 cases of Rapunzel syndrome with a large bezoar in paediatric age group that presented with features of acute intestinal obstruction. They were managed with surgical exploration.

Migration of a Percutaneous Endoscopic Gastrojejunostomy Tube into the Colon with Small Intestinal Telescoping

Continuous duodenal levodopa/carbidopa intestinal gel delivery by a gastrostomy infusion system improves control of Parkinson’s disease. The overall complication rates of percutaneous endoscopic gastrojejunostomy were reported to be 41% and 59% for immediate and delayed adverse events, respectively. A 72-year-old woman underwent percutaneous endoscopic gastrojejunostomy using the delivery system noted above. Abdominal pain and vomiting occurred 3 months later. Esophagogastroduodenoscopy showed a longitudinal ulcer extending from the lower gastric body to the ileum end, with small intestinal telescoping. Colonoscopy showed a large bezoar of food residue that was attached around the tip of the tube, reaching the ascending colon, which may have acted as an anchor. Thus, the gastric antrum and small intestine were shortened with telescoping. This complication was resolved by crushing the bezoar with forceps during colonoscopy and can be prevented by consuming a fiber-free diet and periodic exchanges of the tube using esophagogastroduodenoscopy.

1729 An Unusual Case of Ventilatory Compromise and Mega-Esophagus

INTRODUCTION: Mega-esophagus, usually due to achalasia or pseudoachalasia, can cause bronchial compression when filled with phytobezoars. We present a case of mega-esophagus not due to achalasia but with profound ventilatory consequences. CASE DESCRIPTION/METHODS: A 67 year old alcoholic man presented with 24 hours of increasing dyspnea at rest. He denied fevers, chills, cough, chest pain, heartburn, dysphagia, abdominal pain or weight loss. On physical exam he was somnolent but arousable. He was able to speak in full sentences. Lungs revealed right sided rhonchi. He was afebrile, BP 211/100, pulse 68, respiratory rate 18, and O2 saturation 80-85% on room air which improved to 94% after 4L nasal O2. Urine toxicology was positive for opiates and cocaine. Chest CT showed a 6.8 cm esophagus filled with debris. It was herniated into the right upper thorax and terminated in a narrow taper at the aortic arch. The trachea deviated rightward and narrowed to 4 mm. The proximal left main-stem bronchus was narrowed to 2 mm. The right upper lobe showed scarring, cystic bronchiectasis, and pleural thickening. On day 2 the patient developed severe dyspnea and orthopnea. O2 saturation varied with position. After intubation and transfer to the ICU for treatment of acute ventilator failure, GI was consulted to decompress the mega-esophagus presumed due to end stage achalasia. EGD initially revealed a dilated esophagus with a phytobezoar. Upon partial clearing two lumens were noted: one containing more food and one which lead to a normal distal esophagus, stomach, and duodenum. The first opening was a large diverticulum located about 20 cm from the incisors and was filled with recently ingested food. Transfer to a tertiary care center was recommended to manage possible total airway collapse. There, repeat chest CT showed a distended esophagus to the level of the aortic arch with no compression of the airways. Esophagram was not consistent with achalasia but demonstrated a large bezoar filled diverticulum. Repeat EGD was done to complete bezoar removal. Patient’s respiratory status normalized. Elective esophagectomy was planned, but the patient was lost to follow up. DISCUSSION: Our patient likely had a traction diverticulum as he gave no antecedent history of heartburn or dysphagia and the food in the bezoar was not fermented. In addition, his distal esophagus appeared normal on barium swallow. This is may be the first reported case of airway compression due to mega-esophagus due to a traction diverticulum.

Do You Eat Healthy? You May Need a Diet Coke! A Case Report of Successful Non-Surgical Phytobezoar Treatment

Cola drinks have become increasingly targeted as dangerous beverages that only increase the risk of diabetes, heart disease, and obesity. However, for certain types of abdominal pain caused by gastric phytobezoars, it is exactly the therapy we need. Phytobezoars are composed of accumulated vegetable material, but there are bezoars composed of hair and medications as well. Risk factors include gastric dysmotility due to previous vagotomy or pyloroplasty, use of opiates and anticholinergics, or prior gastric outlet obstruction. While most remain asymptomatic, they can cause complications such as abdominal pain, obstruction, and anorexia. Surgery can provide definitive treatment for severe cases, however we present an instance where chemical dissolution proved to be a successful alternative. A 62 year old male with a history of Billroth-II bypass surgery 25 years ago and multiple episodes of small bowel obstruction presented with severe left upper quadrant abdominal pain, vomiting, and nausea after eating pizza an hour earlier. An abdominal CT revealed copious amounts of material in a severely dilated stomach. Afterwards, an EGD showed 50% of the stomach obscured by a large gastric bezoar which was unable to be suctioned or passed via endoscopic water jet. The patient was treated with 500 cc of diet cola via gastric lavage BID for seven days for bezoar dissolution. Afterwards, the patient's symptoms resolved and he was discharged after tolerating a full diet without complications.Therapy for bezoars vary depending on their composition, and interestingly for phytobezoars the high sodium bicarbonate content in cola drinks is believed to create carbon dioxide bubbles that dissolve gastric contents. Dosages may vary from 500 cc to 3 L per day for several weeks with or without a combination of other prokinetic agents. Other options include cellulase tablets, papain meat tenderizer, or acetylcysteine via nasogastric tube. To prevent recurrence, patients should be advised to avoid high fiber diets, chew their food carefully, and stay well hydrated. This case represents an important reminder that clinicians should expand their differentials to include gastric bezoars when evaluating for possible causes of acute upper abdominal pain, especially in patients with prior gastric surgery. Although unusual, the existence of cola drinks as a cost-effective and available therapy should be stressed to clinicians to prevent unnecessary endoscopic or surgical treatment.2706_A Figure 1. CT Abdomen showing faecalized gastric contents causing severe gastric dilatation2706_B Figure 2. Large Bezoar occupying 50% of the stomach pouch

Endoscopic shaving of hair in a gastric bypass patient with a large bezoar

Trichotillomania can be associated with the formation of trichobezoars (hair ball) usually located in the stomach. Trichobezoars may lead to complications including bowel obstruction, and perforation. Patients with a history...

Case Report of Foreign Body Stuck in Esophagus with Failure of Endoscopic Management in a Man with a History of Pica

This is a case report of foreign body ingestion in a 55-year-old intellectually disabled man with a history of pica and previous removal of ten plastic gloves from his rectum four months prior to this presentation. The patient presented after ingesting plastic gloves which formed large, rigid esophageal and gastric bezoars that were not amenable to endoscopic removal. An exploratory laparotomy and gastrostomy was performed, and a 10 × 4.5 × 2 cm gastric bezoar consisting of rigid plastic gloves was removed without complication. Special considerations must be taken when considering the ingestion of nonfood items in the intellectually disabled population as these cases may not present classically with symptoms of a gastric bezoar.

A Case Report

Rapunzel syndrome is very rare gastric foreign bodies that occur in children. It is a severe condition of a gastric trichobezoar with a long tail that passes into the small intestine. Here, we present the case of an 8-year-old girl with Rapunzel syndrome due to a very large (7 × 7 × 30 cm) gastric trichobezoar. The patient had trichotillomania and trichophagia for 1 year prior to presentation. Ideally, small bezoars are removed through a minimally invasive method, such as endoscopic fragmentation. However, large trichobezoars, including those in Rapunzel syndrome, can only be managed with open surgical extraction, despite the large scars that may result.We report a case of Rapunzel syndrome with a large bezoar that was surgically removed after it was endoscopically cauterized with argon plasma. Endoscopic precutting was used to effectively reduce the size of the bezoar.

Gastric Bezoar After Vagotomy and Billroth I Resection: An Intriguing Complication of a Historical Surgery

Introduction: Bezoars are collections of undigested food that accumulate in the GI tract. They could occur after gastric surgery due to low acid milieu and slow peristalsis. Vagotomy and Billroth resections are culprit surgeries. Patients are often asymptomatic or display symptoms indistinguishable from other GI disorders resulting in delayed diagnosis and potential complications. Case Report: 55-year-old man with vagotomy and Billroth I, 25 years ago presented with right upper quadrant (RUQ) pain, nausea and vomiting. Exam revealed RUQ tenderness. Chemistry revealed bilirubin of 1,4. Ultrasound showed gallbladder sludge and 7 mm common bile duct. HIDA, CT and MRCP were negative. Symptoms were attributed to biliary colic. A month later, pain recurred with vomiting of undigested food. Gastric outlet obstruction (GOO) was suspected. EGD revealed a large gastric bezoar. Fragmentation with a polypectomy snare failed due to hard consistency (Fig 1). Patient was referred for laparoscopic surgery where a 10x10x3 cm phytotrichobezoar was removed using an endobag (Fig 2). Patient did well thereafter. Discussion: Bezoars are a rare cause of GOO. They often present with vague symptoms. Large bezoars may lead to GOO, pressure ulcers and GI bleed. Recognition of highrisk patients and subtle clinical clues may assist in early diagnosis and prevention of complications. EGD is the test of choice and offers therapy like fragmentation or dissolution. If that fails, surgical extraction is recommended. Traditionally, bezoars were removed by laparotomy. Recently laparoscopic extraction through an anterior wall gastrotomy in an endobag, as in our patient, is slowly growing to be the intervention of choice.Figure 1: Attempt to break up the bezoar.Figure 2: Laparoscopic removal of gastric bezoar.

A Large-Sized Phytobezoar Located on the Rare Site of the Gastrointestinal Tract

Bezoars are concretions of undigested material and are most often observed in the stomach. They can occur at any site in the gastrointestinal tract; however, duodenal localization is very rare. We report the case of a 71-year-old male who had undergone subtotal gastrectomy with gastroduodenostomy and experienced severe epigastric discomfort, abdominal pain, and vomiting for a few days. An approximately 7×8 cm-sized mass was found on an abdominal computed tomography scan. On following endoscopy, a large bezoar was revealed in the duodenum and was removed using an endoscopic removal technique, assisted by a large amount of Coca-Cola infusion.

Protein Bezoar: A Rare Complication of Enteral Nutrition

Purpose: 54-year-old male s/p orthotopic liver transplantation for hepatitis C induced cirrhosis. On the third postoperative day he was started on total parentral nutrition (TPN). On post operative day nine, a nasogastric tube (12 french) was inserted, and was started on enteral feeding with a non-fiber containing formulae for renal patients (Nepro). Feeding was started at 10 ml/hr rate was doubled every six hourly to attain a goal of 40 ml/hr. On day 13 beneprotien was added (14 gms three times daily) to meet the protein requirements. After one week of starting the patient on beneprotien, he developed abdominal pain, and high residuals. X ray of the abdomen revealed dilated loops of small bowel in the left lower quadrant suggesting ileus or partial obstruction. Patient was kept NPO for a day to allow self resolution of the symptoms. A follow up CT scan of the abdomen on the second day of abdominal pain revealed an increase in small bowel distention with a transition point seen involving distal ileal loop. The obstruction appeared secondary to a large bezoar in the distal ileum with proximal dilation and distal decompression. Obstruction persisted despite the Gastrografin given for the CT scan with minimal progression of the bezoar. He underwent explorative laprotomy revealing a mass of 5 cm in diameter with very thick soft consistency. We created a small enterotomy to fully decompress the bowel and remove the bezoar material, composed of very thick chalky material. The chemical analysis of the material identified as whey protein, a component of beneprotein. Discussion: As long as the patient has a viable GI tract, enteral nutrition remains the preferred and physiologic route of food application. Total parentral nutrition indicated only when the patient lack a functioning GI tract or his/her illness demands completes bowel rest. Enteral nutrition has a low complication rate (1.6%-2.7%) compared to TPN (> 50%). Long term TPN leads to adult glucose intolerance and hypertriglyceridemia, hepatic steatosis and increased fibrosis in the graft. The complications of enteral feedings are very rarely reported (0.3-0.8%) and most of them are procedure related during the insertion of tube. Bezoars account for 3-4% of the small bowel obstruction. Bezoar formation in postoperative patients from enteral feeding is extremely rare. Most cases were associated with the use of increased fiber containing formulae. Factors contributing to the bezoar formation are impaired bowel motility, decreased intraluminal acidity, increased flow rate of the nutritional formulae leading to accumulation of the formulae within the GI tract, advanced age of the patient and, previous bowel surgeries.

Laparoscopic Intragastric Removal of Giant Trichobezoar

Gastric bezoars are a rare clinical entity, most commonly observed in patients with mental or emotional illness. Large bezoars can be difficult to remove laparoscopically without extending a port incision. We report the case of a large symptomatic trichobezoar with Rapunzel syndrome that occurred in a 17-year-old girl who had trichotillomania. The bezoar was removed laparoscopically, in piecemeal fashion, through a gastrotomy port. This procedure did not require an extension of any incision, nor did it require the contents of the stomach to directly touch the incision, thereby reducing the risk of infection. The patient was discharged home, on the fourth postoperative day, free of any complications. This case illustrates the safety of the laparoscopic approach in the removal of large gastric bezoars. In considering use of this approach, the potentially long operative time must be weighed against the benefits of both minimal risk of infection and minimal incisions.

Laparoscopic Removal of a Gastric Trichobezoar in a Pediatric Patient

Trichobezoars from the ingestion of hair typically develop into a large, spherical foreign body within the stomach. Due to the frequently large size, endoscopic removal is usually not feasible beyond diagnosis. Likewise, the size often has forced surgeons to remove these trichobezoars via laparotomy. Laparoscopic removal of gastric trichobezoars has been reported, but the concern with this technique is that the complete removal of the large bezoar without spillage of hairs in the peritoneal cavity may be difficult. As such, most of the reports are laparoscopic assisted, but still utilize an extended incision to facilitate direct removal from the peritoneal cavity. In this case, we describe in this paper the complete laparoscopic removal of a giant trichobezoar in a 10-year-old child without spillage, using piecemeal removal through the umbilical incision without extending the incisions.

Giant Gastric Trichobezoar In A Female Teenager

Trichobezoar is a rare pathology in which swallowed hairs accumulate in the stomach. Large amounts can thus accumulate over the years forming a hair ball. The usual presentatation is with early satiety and malnutrition. The diagnosis may be suspected in young females with abdominal pain, epigastric mass and malnutrition, who have a history of trichophagia. A small trichobezoar can be treated using non-surgical methods, but large bezoars usually require open surgery. In this report, we present one case of a successful laparotomy removal of a giant (500g) gastric trichobezoar in a 17-year-old girl with a 1-year history of trichotillophagia. Physical examination revealed diffuse abdominal pain and an epigastric mass. Psychodynamic aspects, clinical maifestations, diagnosis and therapautic strategies are discussed.

Laparoscopic Removal of a Huge Gastric Trichobezoar in a Patient With Trichotillomania

Gastric bezoars are rare, and are commonly observed in female children with mental or emotional disorders. Large bezoars may not be suitable for endoscopic extraction and are conventionally removed at laparotomy. We present a 19-year-old girl who had trichotillomania with a symptomatic abdominal mass that represented a 17-cm gastric trichobezoar. This was removed laparoscopically through a gastrotomy in a water-impervious bag and was extracted piecemeal through a 4-cm extension of one of the port wounds. The bezoar weighed 720 g. She was discharged home on the third postoperative day and remains symptom-free at 12-month follow-up. Laparoscopic removal of large gastric trichobezoars is feasible and appears safe.