Large Phytobezoar Research Articles

Tennis ball cord combined with endoscopy for giant gastric phytobezoar: A case report

BACKGROUND Due to the specificity of Chinese food types, gastric phytobezoars are relatively common in China. Most gastric phytobezoars can be removed by chemical enzyme lysis and endoscopic fragmentation, but the treatment for large phytobezoars is limited, and surgical procedures are often required for this difficult problem. CASE SUMMARY For giant gastric phytobezoars that cannot be dissolved and fragmented by conventional treatment, we have invented a new lithotripsy technique (tennis ball cord combined with endoscopy) for these phytobezoars. This non-interventional treatment was successful in a patient whose abdominal pain was immediately relieved, and the gastroscope-induced ulcer healed well 3 d after lithotripsy. The patient was followed-up for 8 wk postoperatively and showed no discomfort such as abdominal pain. CONCLUSION The combination of tennis ball cord and endoscopy for the treatment of giant gastric phytobezoars is feasible and showed high safety and effectiveness, and can be widely applied in hospitals of all sizes.

S3547 Cellulase With Prokinetics Is an Effective Dissolution Therapy for Gastric Phytobezoars

Introduction: Gastric phytobezoars are hard concretions of ingested vegetable/food matter in the stomach. They can significantly impair mucosal visualization during esophagogastroduodenoscopy (EGD). In the absence of outlet obstruction, dissolution therapy is recommended as a first step whilst evaluating for underlying causes. Different dissolution therapies for bezoar have been described. Cellulase, although first described in 1980’s has not been systematically examined and whether combined therapy with prokinetics is more effective is unknown. We describe two patients with large gastric phytobezoars found on EGD and successfully treated with cellulase plus adjuvant azithromycin for 5 days. Case Description/Methods: Case 1: A 37-year-old Caucasian woman with type 2 diabetes mellitus (DM), gastroparesis and obesity presented with a 2-year history of worsening GERD, dyspepsia, early satiety and Gastroparesis Cardinal Symptom Index (GCSI) of 24. EGD revealed a large phytobezoar, occupying 60% of stomach (Fig. 1a). She was treated with Cellulase 5 g dissolved in 200 ml of water, daily for 5 days on an empty stomach, and azithromycin 125 mg liquid bid for 3 weeks. She reported significant symptom improvement in 1 week. Repeat EGD after 2-3 weeks showed normal stomach with no bezoar (Fig. 1b), and GCSI improved to 18. Case 2: A 64-year-old Caucasian woman with Type 2 DM and gastroparesis presented with worsening nausea, vomiting, early satiety and GCSI of 22. Examination noted mild epigastric fullness with tenderness and succussion splash. EGD noted a large gastric bezoar occupying the 75% of stomach. She was treated with aforementioned regimen. EGD after 2 weeks was normal with no bezoar (Fig. 1c), and GCSI improved to 16 (Figure). Discussion: Gastric bezoars are rare with an estimated incidence of 0.3% on EGD. Risk factors include gastric dysmotility, gastric outlet obstruction, anticholinergic agents/opioids or psychiatric problems. They can be asymptomatic or cause abdominal pain, nausea, vomiting or early satiety. Agents used for chemical dissolution therapy (CDT) with varying results include cellulase, carbonated drinks, papain and acetylcysteine. Both of our patients had gastroparesis with poorly controlled DM and intolerance to metoclopramide. Possible risks of CDT include possible small bowel obstruction from partially dissolved bezoars. Combination therapy with Cellulase (5G), and Azithromycin (125 mg liquid bid, prokinetic) was safe and effective therapy for gastric phytobezoars without luminal obstruction.Figure 1.: 1. Endoscopic images (Patient 1) showing large phytobezoar (a) and repeat EGD in 2 weeks showing normal stomach after dissolution therapy (b). Normal EGD (patient 2) after dissolution therapy (c).

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.

Endoscopic treatment of a large gastric bezoar: A Case report

Bezoars are concretions of undigested or partially digested foreign material in the gastrointestinal tract. They occur in patients with altered gastrointestinal motility or anatomy (previous gastricsurgery, diabetes mellitus, neurological disorders). They are rare, with an estimated %0.3 on upper endoscopy. The most common symptoms include abdominal pain, nausea, vomiting, early satiety, anorexia, and weight loss. We present a patient who diagnosed with 8-9 cm phytobezoar, and treated by endoscopic method. An 87 years old woman presented to our emergency room with upper abdominal pain, nausea, and postprandial emesis for 3 days. Emergency esophagogastroduodenoscopy revealed prepyloric antrum, gastric phytobezoar (8-9 cm) and ulcers (10-12 mm). We used an endoscopic snare to cut the bezoar into several pieces. After endoscopy, all bezoars disappeared. There was no recurrence during 1-year follow-up. In conclusion, endoscopic treatment may be a safe and viable option for the extraction of gastric bezoars presenting with gastric outlet obstruction. This is the rare case that such a large phytobezoar (8×9 cm) has been fragmented with an ordinary polypectomy snare.

Removal of a Small Bowel Bezoar Causing Bowel Obstruction via Mechanical Compression after Metal Stent Placement

Small bowel obstructions (SBOs) that develop for various reasons often require prompt medical treatment. Migration of a gastric bezoar (indigestible foreign material that has accumulated in the stomach) is a rare cause of SBO. Treatment of a symptomatic SBO caused by a bezoar requires a multidisciplinary approach that considers the patient’s physical status and comorbidities and the bezoar volume, location, and pathology. Although surgery is the treatment of choice, endoscopic treatments such as fragmentation and retrieval may serve as alternatives. We present the first case of resolution of a large phytobezoar via mechanical compression after covered metal stent insertion, followed by stent retrieval, in a patient with a symptomatic SBO that persisted even after two sessions of push-endoscopic fragmentation.

Intestinal Phytobezoar: A Rare Case Report

A bezoar is the result of the ingestion of indigestible or poorly digestible substances that accumulate in the gastrointestinal tract in the form of a mass. Among different types of bezoars phytobezoars is the most common type and formed by excessive consumption of herbal nutrients containing high amounts of indigestible fibers. There are some predisposing factors for gastrointestinal phytobezoars formation such as loss of pyloric function, decreased gastric motility, malabsorption, inadequate chewing and excessive consumption of herbal indigestible fibers. Small bowel obstruction is the most common major complication of phytobezoars. We present a rare case of intestinal obstruction in a middle aged man who was previously diagnosed to have malabsorption and used to take herbal medicine. He was treated successfully by right hemicolectomy under general anesthesia. On histopathological examination a large phytobezoar was found in the terminal part of ileum.Birdem Med J 2017; 7(1): 64-67

A Rare Case of a Congenital Duodenal Web in an Adult Patient

Case: A 24 year-old female presented with postprandial bloating, heartburn and occasional vomiting for the last couple of months. Her abdomen is distended on exam with no significant tenderness. She underwent an upper endoscopy that showed erosive esophagitis and a large phytobezoar in the stomach that prevented advancing the scope further. A repeat esophagogastroduodenoscopy revealed a dilated stomach and duodenal bulb with suspected duodenal stricture. X-ray of the stomach with gastrograffin demonstrated significant dilation of the duodenal bulb with delay of the contrast material passage beyond this region raising the possibility of a congenital duodenal web. Computed tomography of the abdomen reported significantly distended first and second portions of the duodenum. Patient underwent a repeat EGD that showed again a web-like constriction in the third part of the duodenum that was balloon dilated to 12 mm. The standard upper endoscope did not reach to the stricture area; therefore this was exchanged for a pediatric colonoscope for dilation. The patient never had anemia or nutritional deficiencies of any kind. Post dilation, the patient felt improvement in her symptoms and she is planned to have a second dilation later on. Discussion: Congenital duodenal anomalies are rarely diagnosed in adulthood. Patients with duodenal webs usually present with epigastric discomfort, bloating and postprandial emesis. These malformations infrequently cause intestinal obstruction. Because of the gastric outlet obstruction, acid reflux symptoms and heartburn are very common. Occasionally, they remain asymptomatic until adulthood and, because they are unusual, may not be diagnosed. Most of patients with duodenal webs have weight loss, nutritional deficiencies and anemia. Our patient was gaining weight instead, which made the suspicion for her having a gastrointestinal malformation unlikely on presentation. Acquired duodenal webs reported in the literature are mostly associated with NSAIDs use, previous abdominal surgeries or pancreatitis. Our patient does not have any medical problems and her symptoms started during her childhood but went unnoticeable till her reflux symptoms were refractory to acid suppression therapy. Management strategies are related to the degree of obstruction; they range from balloon dilation to duodenal web excision. Surgical correction is usually the definitive treatment to restore the intestinal continuity.

An Unusual Cause of Duodenal Obstruction: Persimmon Phytobezoar.

Duodenal phytobezoar, an unusual cause of acute duodenal obstruction, is rarely seen. The most common cause of this type of bezoar is persimmon. It frequently arises from underlying gastrointestinal tract pathologies (gastric surgery, etc.). Here, we report the case of a 66-year-old man who had undergone distal gastrectomy with Billroth I reconstruction for gastric cancer and experienced severe epigastric discomfort, abdominal pain, and vomiting for a few days. The abdominal computed tomography scan showed a large-sized mass in the horizontal portion of the duodenum. On following endoscopic examination, a large phytobezoar was revealed in the duodenum. He was treated with endoscopic fragmentation combined with nasogastric Coca-Cola. The patient tolerated the procedure well and resumed a normal oral diet 3days later.

Cellulase treatment in 3 cases of large phytobezoars

IntroductionA bezoar is a hard mass of undigested foreign matter found in the gastrointestinal system. The most common type is the phytobezoar, which is composed of vegetable fibres. There is no current consensus as to its treatment. Three cases of phytobezoars treated with cellulase are described. Patients and methodCase 1: patient with large gastric phytobezoar. Initial treatment with nasogastric cola drink lavages was ineffective. Subsequent treatment with cellulase was successful. Case 2: patient with gastric phytobezoar who was treated with cellulase and metoclopramide. Definitive fragmentation was performed with the endoscopy technique. Case 3: patient with large intestinal phytobezoar. The patient was treated by endoscopic lysis with partial success. Subsequent treatment with cellulase led to complete disintegration. In all the cases, cellulase was administered in pure form by nasogastric tube, and none of the patients suffered adverse effects. ConclusionsTreatment with cellulase is based on the enzymatic degradation of the bezoar. It has been shown to be effective as the treatment of choice in earlier studies with few patients. This agent seems to be a good alternative for patients with large phytobezoars.

Obstructing phytobezoar arising from proximal jejunal diverticulum

The following report illustrates a rare case of small bowel obstruction which occurred when a large phytobezoar, which had formed in a proximal jejunal diverticulum, dislodged and migrated distally. Obstruction and subsequent perforation resulted when the phytobezoar passed into the narrow terminal ileum and lodged just proximal to the ileocecal valve. The images are presented for educational purposes.

PHYTOBEZOAR

Objectives: We are presenting a case report of an11 year old boy brought in emergency with acute intestinal obstruction. An exploratory Laparotomy revealed two stonyhard large phytobezoars to be the cause of the acute small intestinal obstruction at terminal ileum. Enterotomy wasdone to remove the bezoars and patient had smooth recovery.

Laparosopic Removal of Large Gastric Phytobezoars

Large gastric bezoars are difficult to remove endoscopically. A 78-year-old man presenting with abdominal pain and loss of appetite for 4 months was admitted and evaluated. Gastroscopy disclosed two large phytobezoars within the stomach. Laparoscopic removal was undertaken. The bezoars were removed via a gastrotomy using the three-trocar technique. They were successfully retrieved from the abdominal cavity using an improvised "endobag" made from a simple surgical glove. Such an endobag presents several advantages; they are easy to make, sterile, economical, readily available, disposable, there is ample space to manipulate the specimen within, and there is minimal risk of contamination throughout the procedure. The authors recommend this approach for the treatment of patients with large gastric bezoars in whom laparotomy is indicated.

Endoscopic Management of Gastric Phytobezoars — Report of a Case

Abstract: We report a case of two large stomach phytobezoars whose removal from the stomach was achieved by means of endoscopic fragmentation. The patient was a 42‐year‐old who had a history of vagotomy with pyloroplasty and practiced excessive consumption of fruits and vegetables; a follow‐up endoscopy revealed two large phytobezoars attached to the mucosa of the fundus and corpus. In two sessions, the phytobezoars were fragmented with large‐diameter polypectomes and a third endoscopy revealed no sign of the remaining parts, which had obviously passed through the pylorus and had been excreted with the feces. The successful endoscopic management of the phytobezoars in this case suggest that this procedure may be the treatment of choice in such cases, especially since surgery and its potential complications are avoided. (Dig Endosc 1999; 11: 165–168)

Bezoars and Foreign Bodies of the Stomach

Bezoars are usually encountered in patients with altered gastric anatomy or function. Symptomatic, large phytobezoars or trichobezoars may require endoscopic fragmentation or surgical removal. Foreign bodies of the stomach are usually a self-limited problem, because at least 90% pass without symptoms, in patients with normal gastrointestinal anatomy. Endoscopic removal should be considered for sharp, pointed, or long objects, or in patients with altered anatomy, such as intestinal stricture.

Importance of chronic aspiration in recipients of heart-lung transplants

In a series of eleven recipients of heart-lung transplants (HLT), five have obliterative bronchiolitis. Five of the eleven patients have chronic cough as well as slower than normal gastric emptying and/or oesophageal dysmotility; all five have evidence of bronchiectasis and three have obliterative bronchiolitis. Three of the patients improved after the introduction of treatment to prevent reflux, and another, who had a large phytobezoar, improved after pyloroplasty. In patients with chronic cough after HLT, with or without dyspeptic symptoms or recurring pulmonary sepsis, investigation of oesophageal motility and gastric emptying should be undertaken.

Bezoar Therapy

• A 65-year-old patient with a 95% gastrectomy was treated with Adolph's Meat Tenderizer because of a large phytobezoar in her gastric remnant. Hypernatremia (serum sodium level, 160 mEq/L) and confusion were found to rapidly develop following initiation of treatment, a complication not previously reported, to our knowledge. It was believed that Adolph's Meat Tenderizer was the cause because of its high sodium content. Another method of bezoar dissolution should be considered, particularly in patients with potential for salt retention. (<i>Arch Intern Med</i>1981;141:1669-1670)