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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 282-283

An unusual case of phytobezoar causing gastric outlet obstruction


1 Department of Surgery, Wockhardt Hospital, Mira-Bhayandar, Mumbai, Maharashtra, India
2 Department of Surgery, Grant Government Medical College and Sir J.J. Group of Hospitals, Mumbai, Maharashtra, India

Date of Submission31-Jan-2021
Date of Acceptance03-May-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. Aditi Shivcharan Agrawal
Wockhardt Hospital, Mira Road, Mira-Bhayandar, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_18_21

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  Abstract 


A bezoar is defined as the accumulation of certain indigestible or poorly digestible substances in the gastrointestinal tract in the form of a mass, and when the bezoars consist of fruits and vegetables fibers, they are labeled as “phytobezoar.” Bezoars in the stomach are a rare condition and are often associated with episodes of gastric dysmotility and prior gastric surgery, though sometimes they can present without any significant history. Phytobezoars are difficult to diagnose due to its overlapping signs and episodic nature. however, in medical literature, the information about phytobezoars is insufficient due to the limited amount of documented cases, as well as the lack of research about this topic. in this case report, we present a rare case of gastric outlet obstruction with signs and symptoms overlapping with gastric carcinoma. On further investigation, the obstruction was found to be due to ingestion of unidentified type of vegetable fibers causing food impaction and phytobezoar formation for a 72-year-old patient with no former history of any type of surgeries.

Keywords: Bezoars, gastric bezoar, gastric outlet obstruction, phytobezoars, management


How to cite this article:
Agrawal AS, Mishra T. An unusual case of phytobezoar causing gastric outlet obstruction. Indian J Health Sci Biomed Res 2021;14:282-3

How to cite this URL:
Agrawal AS, Mishra T. An unusual case of phytobezoar causing gastric outlet obstruction. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Jun 17];14:282-3. Available from: https://www.ijournalhs.org/text.asp?2021/14/2/282/317398




  Introduction Top


The word “bezoar” stems from either the Arabic term “badzehr” or the Persian world “padzahr,” both of which mean counter-poison or antidote. There are different types of bezoars depending on its content.[1] Some of the bezoars that have been reported until now include – phytobezoar – composed of plant material fibers; trichobezoar – composed of hair; lactobezoar –formed in an infant from constant intake of inspissated milk; pharmacobezoar – formed by sustained release medication; lithobezoar – formed by rock-like substances or combination-like trichophytobezoar.[1]


  Case Report Top


A 72-year-old female patient came to a clinic with a complaint of dysphagia for the past 3 months. She had difficulty having solid food more than liquid food, as a result of which she completely stopped eating solid food and was only on liquid food. She experienced loss of appetite and had lost 12 kg of bodyweight within a span of 2–3 months. She also experienced abdominal discomfort and vomiting. However, there was no acute abdominal pain. The findings on clinical examination were unremarkable. There was no palpable mass, organomegaly or guarding, and tenderness and rigidity. Our patient's history included hypertension, diabetes mellitus, and ischemic heart disease. The results of routine hematological and biochemical laboratory studies revealed only anemia with hemoglobin levels at 8.3 gm/dl. An abdominal computed tomography (CT) scan with contrast medium showing impacted good residue or hamartomatous polyp in pyloric lumen. Endoscopy with standard endoscope was performed by an expert endoscopist to establish the diagnosis. Endoscopy could not detect the presence of any mass rather suspected the presence of a good bolus. Forced lavage was performed to flush out the bolus, but the procedure was not successful. Thus, an exploratory laparotomy was planned. A phytobezoar of 3.8 cm × 2.5 cm × 1.9 cm was removed from pyloric canal. A pathologic examination of the intraluminal lesion revealed the presence of a phytobezoar made of different types of fibers.


  Discussion Top


Bezoars are rare clinical entities of the gastrointestinal (GI) tract that comprises formation of conglomerates of inedible materials (fibers, hair, etc.) that remained trapped in the stomach (more frequently) or in the intestine. This can result in various complications such as intestinal obstruction, erosive gastritis, esophagitis, pressure ulcers, and bleeding. Phytobezoars are more likely to occur in elderly patient with risk factors including GI dysmotility, delayed gastric emptying, previous gastric surgery, diabetes, or endocrine diseases.[2] Bezoars occur more frequently in certain areas or cultures with a high consumption of vegetables and fruits rich in fibers. Some of the predisposing factors for the formation of GI phytobezoars include loss of pyloric function, decreased gastric motility as well as acid secretion following gastric surgery, and adhesions due to abdominal surgery, inadequate chewing, and excessive consumption of herbal nutrients including high amounts of indigestible fibers.[3]

Various imaging modalities can be used to diagnose gastric outlet obstruction – some of the common findings obtained include dilated intestinal loops, air–fluid levels, and thickened intestinal wall in plain abdominal radiographs. Ultrasonography shows echogenic intraluminal mass having acoustic shadowing. Air bubbles containing intraluminal mass with dilated proximal bowel are seen on CT.[4] A number of operative and nonoperative techniques have been described in the literature for the management of gastric phytobezoars. Administration of medications such as prokinetic agents and lytic enzymes has been commonly practiced by various medical professionals. A literature review conducted by Walker-Renard reported 34 cases during a period of 1966 to 1993 in which bezoars were treated with administration of cellulase and papain.[5] However, endoscopic fragmentation or aspiration remains the best alternative among various noninvasive procedures used and should be preferred to surgical treatment. Surgical procedures may be undertaken in case of complicated cases in which small bowel occlusion or GI perforation has developed. Various techniques have been described for endoscopic treatment of bezoars: some of popular methods include fragmentation with biopsy forceps,[6] use of polypectomy snares,[7] lithotripsy,[8] and aspiration with a large channel endoscope.[9] However, large size of gastric bezoars frequently needs time-consuming or multiple sessions to obtain a complete fragmentation. In our case, the patient's history and CT images initially drove us to the diagnosis of tumoral gastric occlusion – bezoars were not considered at that time. For this reason, we decided on a median laparotomy, which allowed us to determine the real cause of obstruction.

Mortality and morbidity rates are low in case of bezoars if treated early. Krausz et al. reported that early morbidity and mortality rates of bezoars were 11.5% and 1.7%.[10] However, no mortality and 7.6% morbidity were observed in the study conducted by Ertuğrul et al.[1]

Unfortunately, the rarity of these entities has impaired the possibility of an extensive clinical evaluation. Therefore, clear recommendations concerning clinical management are still lacking. Assessing and planning the most appropriate procedure are nonetheless crucial.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ertuğrul G, Coşkun M, Sevinç M, Yelimlieş B, Ertuğrul F, Toydemir T. A rare cause of gastrointestinal phytobezoars: Diospyros lotus. World J Emerg Surg 2012;7:19.  Back to cited text no. 1
    
2.
Cifuentes Tebar J, Robles Campos R, Parrilla Paricio P, Lujan Mompean JA, Escamilla C, Liron Ruiz R, et al. Gastric surgery and bezoars. Dig Dis Sci 1992;37:1694-6.  Back to cited text no. 2
    
3.
Frazzini VI Jr., English WJ, Bashist B, Moore E. Case report. Small bowel obstruction due to phytobezoar formation within Meckel diverticulum: CT findings. J Comput Assist Tomogr 1996;20:390-2.  Back to cited text no. 3
    
4.
Gayer G, Jonas T, Apter S, Zissin R, Katz M, Katz R, et al. Bezoars in the stomach and small bowel–CT appearance. Clin Radiol 1999;54:228-32.  Back to cited text no. 4
    
5.
Walker-Renard P. Update on the medicinal management of phytobezoars. Am J Gastroenterol 1993;88:1663-6.  Back to cited text no. 5
    
6.
Szántó I, Kiss J. Oesophagus bezoar diagnosed and removed endoscopically. Endoscopy 1976;8:206-8.  Back to cited text no. 6
    
7.
McLoughlin JC, Love AH, Adgey AA, Gough AD, Varma MP. Intact removal of phytobezoar using fibreoptic endoscope in patient with gastric atony. Br Med J 1979;1:1466.  Back to cited text no. 7
    
8.
Lübke HJ, Winkelmann RS, Berges W, Mecklenbeck W, Wienbeck M. Gastric phytobezoar: Endoscopic removal using the gallstone lithotripter. Z Gastroenterol 1988;26:393-6.  Back to cited text no. 8
    
9.
Blam ME, Lichtenstein GR. A new endoscopic technique for the removal of gastric phytobezoars. Gastrointest Endosc 2000;52:404-8.  Back to cited text no. 9
    
10.
Krausz MM, Moriel EZ, Ayalon A, Pode D, Durst AL. Surgical aspects of gastrointestinal persimmon phytobezoar treatment. Am J Surg 1986;152:526-30.  Back to cited text no. 10
    




 

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