When eating makes you sick – Gastric stump obstruction caused by a phytobezoar. A case report and literature review

Introduction and importanceBezoars result from undigested material having an incidence of 0.4–1% (Gunner et al., 2012). Impaired gastrointestinal motility is one of the risk factors. The aim of this article is to highlight the importance of this commonly disregarded entity as well as the different treatment modalities available.Case presentationA 68-year-old female presented to our emergency department complaining of colicky lower left abdominal pain associated with vomiting and absence of bowel movements for the past 4 days. She had a previous history of a subtotal gastrectomy due to gastric cancer. The physical examination revealed a lower left quadrant palpable mass. Abdominopelvic CT scan showed distension of the gastric remnant with anastomotic obstruction caused by a bezoar. Attempted endoscopic dissolution of the bezoar was unsuccessful. The patient then underwent surgery enterotomy proximal to the obstruction with extraction of the mass.Clinical discussionBezoars are responsible for 0.4%–4% of cases of mechanical gastrointestinal obstruction (Dikicier et al., 2015). Contrast-enhanced CT scan is the best diagnostic test with a sensitivity and specificity of 90% and 57%, respectively (Kim et al., 2003). Treatment options differ according to the type, size and location of the bezoar as well as clinical presentation. Conservative measures such as chemical dissolution and endoscopic fragmentation and extraction can be used with surgery being usually required for a bezoar-induced gastrointestinal obstruction.ConclusionThe clinical findings of bezoar-induced ileus do not differ from the other different causes of mechanical intestinal obstruction. Hence, a high grade of suspicion and an early radiological exam are the keys for a prompt diagnosis and treatment.     

Bezoar: an Unusual Palpable Mass in the Right Iliac Fossa

A 64-year-old gentleman presented with a 12-h history of right iliac fossa pain. On examination, the patient had a tender 8 × 6 cm mass in the right iliac fossa with localised peritonitis. The working diagnosis at this time was an appendix mass or caecal cancer. A computed tomography scan revealed the characteristic ‘bird''s nest’ appearance of a bezoar. On further questioning, the patient confessed to regularly ‘binging’ on grapes. The patient described passing the mass and his symptoms completely resolved. This appears to be the only documented case of a bezoar affecting the ascending colon.     

Synergistic effect of multiple predisposing risk factors on the development of bezoars

AIM: To describe the clinical characteristics of patients with gastric or intestinal bezoars recently treated in our hospital.METHODS: In this study, a retrospective chart review of consecutive patients with gastrointestinal bezoars, who were treated at the Samsun Education and Research Hospital between January 2006 and March 2011, was conducted. Data on demographic characteristics, clinical presentation, history of risk factors, diagnostic procedures, localization of bezoars, treatment interventions, and postoperative morbidity and mortality rates were collected and evaluated.RESULTS: Forty-two patients [26 (61.9%) males and 16 (31.1%) females] with a mean ± SD (range) age of 55.8 ± 10.5 (37-74) years were enrolled in this study. Thirty-six patients (85.7%) had one or more predisposing risk factors for gastrointestinal bezoars. The most common predisposing risk factor was a history of previous gastric surgery which was identified in 18 patients (42.8%). Twenty three patients (54.8%) had multiple predisposing risk factors. Phytobezoars were identified in all patients except one who had a trichobezoar in the stomach. Non-operative endoscopic fragmentation was performed either initially or after unsuccessful medical treatment in 14 patients with gastric bezoars and was completely successful in 10 patients (71.5%). Surgery was the most frequent treatment method in our study, which was required in 28 patients (66.7%). Intestinal obstruction secondary to bezoars was the most common complication (n = 18, 42.8%) in our study.CONCLUSION: The presence of multiple predisposing factors may create a synergistic effect in the development of bezoars.     

Blood bezoar causing obstruction after laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

Bowel obstruction is a known complication after bariatric surgery especially Roux-en-Y gastric bypass. The known etiologies include internal hernia, jejunojejunostomy stricture, ileus, intussusceptions, superior mesenteric artery syndrome, incarcerated port site hernia, and adhesions. Blood bezoar is a rare cause of small intestinal obstruction after Roux-en-Y gastric bypass.

PRESENTATION OF CASE

We are going to present two cases of small bowel obstruction after Roux-en-Y gastric bypass due to blood bezoar.

DISCUSSION

Blood clot as the etiology of small bowel obstruction after Roux-en-Y gastric bypass is an unusual event. In the presence of postoperative small intestinal obstruction an obstructive blood bezoar should be in differential diagnosis. As any other etiology of postoperative obstruction it should be treated immediately to prevent its adverse lethal complications.

CONCLUSION

The best way for prevention of blood bezoar is prevention of bleeding at staple line and doing hemostasis at stapler line.     

Acute esophageal obstruction after ingestion of psyllium seed husk powder: A case report

BACKGROUNDBezoar is a mass of hardened external material found in the gastrointestinal (GI) tract. It may form anywhere in the GI tract, but esophageal bezoar is rare because of the short esophageal transit time. Psyllium seed husk is an indigestible natural derivative that is widely used as an herbal laxative. Herein, we report a case of acute esophageal obstruction caused by a bezoar after ingestion of psyllium seed husk powder.CASE SUMMARYA 76-year-old male with Parkinson''s disease visited the emergency department with swallowing difficulty approximately 10 h after ingesting psyllium seed husk powder. Symptoms began a few hours after ingestion and progressed to severe dysphagia. There were no abnormal findings on simple radiography. However, a computed tomography scan revealed an approximately 2.0 cm × 2.5 cm mass located near the gastro-esophageal junction. After grinding, the mass was removed using an endoscopic capture net. Esophageal bezoars may cause life-threatening complications. Patients with Parkinson''s disease may have esophageal motility dysfunction, which may increase esophageal transit time. Since our patient had Parkinson''s disease, this effect may have contributed to the formation of the bezoar.CONCLUSIONAttention should be paid to using bulk-laxatives, and an appropriate specified regimen will be needed when marketed as a dietary supplement.     

Rapunzel syndrome with a fatal outcome in a neglected child

The “Rapunzel” syndrome (a trichobezoar with a long tail extending from the stomach to the small bowel) is an uncommon disease. It is related to severe complications but rarely associates to a fatal outcome. We report a case of a 5-year-old girl admitted at the emergency department in cardiorespiratory arrest whose autopsy disclosed an ileal perforation that is caused by a long bezoar extending from the stomach to the small bowel. The authors discuss a possible link between Rapunzel syndrome and child neglect.     

胆红素和牛黄拮抗正己烷致小鼠脂质过氧化作用的初步研究

目的　探讨胆红素、牛黄和以牛黄为主药的中药组方对正己烷所致小鼠脂质过氧化损伤的拮抗作用。方法　 3 0只CD小鼠随机分为 5组 ,每组 6只 ,分别为对照组、正己烷组和胆红素、牛黄、中药组方组 ,后三组分别先给予胆红素 (15 0 μmol/kg)、牛黄 (2 5mg/kg)、中药 (含牛黄 0 5mg/ml,5 0ml/kg) ,连续给药 3天 ,每天 1次。第 3天同时以正己烷 16 5g/kg体重一次经口染毒 ,第 4天脱髓处死 ,计算脏器系数 ;取血清并制备肝、脑组织匀浆 ,测定总抗氧化能力 (TAOC)、丙二醛 (MDA)和谷胱甘肽过氧化物酶 (GSH Px)水平。结果　正己烷染毒小鼠血清、肝、脑组织中TAOC水平和GSH Px活性降低 ,MDA增高 (P <0 0 5 ) ;分别以胆红素、牛黄和中药组方进行干预可以明显提高血清和组织中TAOC水平和改善GSH Px活力 ,降低MDA水平 (P <0 0 5 )。结论　正己烷引起的小鼠过氧化损伤 ,可为胆红素或牛黄所拮抗 ,含牛黄的中药组方效果似更明显。     

Secretory diarrhea owing to a tape bezoar in a child with Hirschsprung's disease

Bezoars can be composed of a multitude of materials and can present in a wide variety of ways. The authors describe a young boy who had secretory diarrhea caused by an ileal bezoar composed of surgical adhesive tape. This report expands the literature on causes and presentation of intestinal bezoars in children.     

冰敷及牛黄解毒丸膏预防长春瑞滨所致静脉炎疗效的探讨

目的探讨冰敷及自制复方牛黄解毒丸膏预防长春瑞滨所致静脉炎的疗效及护理方法。方法将100例经外周静脉行长春瑞滨化疗的肺癌患者随机分为实验组和对照组,实验组50例,对照组50例。100例的病人均选择一周内未行静脉穿刺的弹性好、粗直的上臂静脉进行穿刺,且一次穿刺成功,回血好,给药过程中局部无红肿,病人自觉无不适。对照组在给药前予地塞米松静脉推注,给药完毕不予其他护理干预。实验组在此基础上局部冰敷,涂擦自制复方牛黄解毒丸膏。比较2组静脉炎发生率。结果实验组静脉炎发生率为8%,对照组为54%,统计学差异显著。静脉炎程度方面,Ⅱ、Ⅲ度静脉炎主要发生在对照组,且对照组发生1例Ⅳ度感染。2组静脉炎发生率比较P<0.05。结论使用冰敷及自制复方牛黄解毒丸膏可明显降低长春瑞滨所致静脉炎的发生率。     

Laparoscopic Removal of a Large Gastric Trichobezoar in a 4-Year-Old Girl

Background:

Standard treatment of large gastric bezoars not amenable to medical or endoscopic management is surgical removal. The optimal operative approach, laparotomy versus laparoscopy, is a contested subject. Though laparoscopic removal has been described, it remains a relatively new technique for surgical management with outcome literature limited to case reports. In addition, currently described laparoscopic techniques often involve limited midline laparotomy incisions or >3 cm extensions of port sites.

Methods:

The following describes the case of a 4-year-old girl with a large gastric trichobezoar.

Results:

The gastric trichobezoar was successfully removed through a 12-mm left lower quadrant trocar incision cosmetically hidden within a skin crease.

Conclusion:

This case, along with accumulating literature, supports the use of laparoscopy to treat large gastric bezoars.