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Pharmacobezoar—a rare case presented as gastric outlet obstruction

Pharmacobezoar—a rare case presented as gastric outlet obstruction BEZOARS are retained concretions of indigestible foreign material that accumulate and conglomerate in the gastrointestinal tract, most commonly in the stomach. Prevalence of bezoar is 0.4%. Bezoars are classified in four categories: phytobezoars; trichobezoars; pharmacobezoars; lactobezoars. A 58-year-old man admitted with complains of pain abdomen and recurrent vomiting since last 3 months. Upper GI endoscopic biopsy reported—chronic gastritis with very occasional non-caseating epitheloid granuloma in lamina propria, no evidence of neoplasia? Crohn’s disease. Keeping Crohn’s as diagnosis patient was given mesalamine 400 mg tid by gastrophyscian. But patient did not respond so the patient was advised surgical man- agement. Repeat UGI endoscopy revealed multiple pills (mesalamine) in the stomach with gastric outlet obstruction (GOO). Around 40 pills were extracted with the help of flower basket, and then patient develope GOO and underwent Laparoscopic gastrojejunostomy and truncal vagotomy. INTRODUCTION CASE REPORT BEZOARS are retained concretions of indigestible foreign A 58-year-old man admitted with complains of pain abdomen and material that accumulate and conglomerate in the gastrointes- recurrent vomiting since last 3 months. USG abdomen was nor- tinal tract, most commonly in the stomach. The term bezoar is mal. CECT abdomen reported a short segment (4.9 cm) of marked derived from the Arabic ‘badzehr’ or from the Persian ‘padzahr’ circumferential wall thickening (20 mm) involving pylorus of both means ‘to expel potion’ or antidote. Prevalence of bezoar stomach. It was causing marked luminal narrowing with mild is 0.4%. Bezoars are classified in four categories: phytobezoars dilatation of stomach? Mitotic? Inflammatory, multiple enlarged (vegetable matter); trichobezoars (hair balls); pharmacobezoars lymph nodes are noted in mesentery and pre–para aortic region. (tablets or semi-liquid masses drugs); lactobezoars (which are Upper GI endoscopic biopsy reported—chronic gastritis with composed of milk protein) miscellaneous material (clay, stone, very occasional non-caseating epitheloid granuloma in lamina etc.) [1]. propria, no evidence of neoplasia? Crohn’s disease. It may lead to intraluminal obstruction. If endoscopic man- Keeping Crohn’s as diagnosis patient was given mesalamine agement (dissolution therapy) fails, surgical intervention is 400 mg tid by gastrophyscian. But patient didn’t respond so the needed and now it can be managed by the laparoscopy Patient was advised surgical management. Barium meal follow approach. through (BMFT) (Fig. 1), reported multiple hyperplastic polyps Received: April 4, 2018. Accepted: May 5, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy116/5017811 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 S.A. Jain et al. Figure 1: BMFT Film, reported multiple hyperplastic polyps with GOO. with gastric outlet obstruction (GOO). Repeat UGI endoscopy revealed multiple pills (mesalamine) in the stomach with GOO (Fig. 2). Around 40 pills were extracted with the help of flower basket, and then patient underwent laparoscopic management of GOO. Surgical procedure done was laparoscopic gastrojeju- nostomy (Fig. 3). Patient also underwent left and right truncal vagotomy (Fig. 4). DISCUSSION The majority of bezoars are located in the stomach. Four differ- ent types of bezoars: Figure 2: UGI endoscopy showing multiple pills. � Phytobezoar—composed of non-digestible food particles found in fruit and vegetables � Trichobezoar—hair bezoar � Lactobezoar—compact mass of undigested milk concretions � Pharmacobezoar—conglomeration of medications � Others � Trichophytobezoar—mixture of hair, fruit, and vegetable fibres � Diospyrobezoar—persimmons � Dead ascaris—worm bezoars [1] Risk factors for bezoar are cystic fibrosis, intrahepatic cho- lestasis, diabetes, hypothyroidism and renal failure. Edentulous patients with poor mastication of food and patients with psy- Figure 3: Gastrojejunostomy by endostaplers. chiatric illness. Cases of gastroparesis with decreased or absent gastric peristalsis, surgical resection/bypass of the gastric antrum and body, or undergoing a bariatric surgery are particu- larly susceptible to the development of bezoars [2, 3]. Medications reported to cause bezoars include aluminium hydroxide gel, enteric-coated aspirin, sucralfate, guar gum, cholestyramine, enteral feeding formulas, psyllium prepara- tions, nifedipine XL, mesalamine and meprobamate. Bowel hypoactivity, dehydration, and concomitant use of anticholin- ergic and narcotic appear to contribute to the propensity for bezoar formation by aluminium hydroxide gel and Isocal. Insolubility of the carrying vehicle of enteric-coated aspirin and Figure 4: Left and right truncal vagotomy. nifedipine is the setting in which these medications form bezoars. In contrast to non-medication bezoars, pharmacobe- zoars may produce additional symptoms, those related to the reducing or stopping the production of natural chemicals release of their active ingredients [4]. Mesalamine is an anti- which cause inflammation, swelling, tissue damage and diar- inflammatory amino salicylate drug used in the treatment of rhoea. It does not get dissolved in acidic media and there is no ulcerative colitis, as well as Crohn’s disease. It works by dissolution therapy available for it [5]. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy116/5017811 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Pharmacobezoar—a rare case presented 3 Pharmacobezoars can present with symptoms of gastric out- index of suspicion in future clinical encounters may be the best let obstruction, but these bezoars can also produce symptoms way to improve diagnostic sensitivity and accuracy. due to their pharmacologic properties such as epigastric pain or discomfort, dyspepsia, postprandial fullness. As a result, CONFLICT OF INTEREST STATEMENT there is an increased potential for drug intoxication in these patients. Complications such as gastrointestinal bleeding (6%) None declared. or intestinal obstruction or perforation (10%). Our patient actually had benign GOO but due to misleading REFERENCES biopsy of Crohn’s disease and mesalamine therapy lead to formation of pharmacobezoar secondary to GOO. 1. Andru CH, Ponskky JL. Bezoars: classification, pathophysi- One should always rule out GOO before prescribing any medi- ology, and treatment. Am J Gastroenterol 1988;83:476–8. cation especially one which does not get dissolve in acidic media 2. Escamilla C, Robles-Campos R, Parrilla-Paricio P, Lujan- otherwise patients may develop pharmacobezoar and that may Mompean J, Liron-Ruiz R, Torralba-Martinez JA. Intestinal lead to diagnostic dilemma. Patient has to undergo many inves- obstruction and bezoars. J Am Coll Surg 1994;179:285–8. tigations and hospitalization, which increases the cost of treat- 3. Robles R, Parrilla P, Escamilla C, Lujan JA, Torralba JA, Liron ment along with the psychological trauma and many days of R, et al. Gastrointestinal bezoars. Br J Surg 1994;81:1000–1. work loss. So this type of secondary pharmacobezoar though 4. Taylor JR, Streetman DS, Castle SS. Medication bezoars: a lit- rare but it’s a new evolving entity and should be kept in mind as erature review and a report of a case. Ann Pharmacother 1998; one of the cause of recurrent upper gastrointestinal problem. 32:940–6. Rules for suspecting, diagnosing, and properly managing a 5. de Albuquerque IC, Carvalho MA, Betista RR, Formiga pharmacobezoar are highly dependent on the pharmaceutical GJS. Bezoar by mesalamine tablet: cause of intestinal agent or agents involved. Becoming familiar with the sparse obstruction in Crohn’s disease. J Coloproctol (Rio J) 2012;32 data available on pharmacobezoars and maintaining a high (4:422-5). Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy116/5017811 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Pharmacobezoar—a rare case presented as gastric outlet obstruction

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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2042-8812
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10.1093/jscr/rjy116
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Abstract

BEZOARS are retained concretions of indigestible foreign material that accumulate and conglomerate in the gastrointestinal tract, most commonly in the stomach. Prevalence of bezoar is 0.4%. Bezoars are classified in four categories: phytobezoars; trichobezoars; pharmacobezoars; lactobezoars. A 58-year-old man admitted with complains of pain abdomen and recurrent vomiting since last 3 months. Upper GI endoscopic biopsy reported—chronic gastritis with very occasional non-caseating epitheloid granuloma in lamina propria, no evidence of neoplasia? Crohn’s disease. Keeping Crohn’s as diagnosis patient was given mesalamine 400 mg tid by gastrophyscian. But patient did not respond so the patient was advised surgical man- agement. Repeat UGI endoscopy revealed multiple pills (mesalamine) in the stomach with gastric outlet obstruction (GOO). Around 40 pills were extracted with the help of flower basket, and then patient develope GOO and underwent Laparoscopic gastrojejunostomy and truncal vagotomy. INTRODUCTION CASE REPORT BEZOARS are retained concretions of indigestible foreign A 58-year-old man admitted with complains of pain abdomen and material that accumulate and conglomerate in the gastrointes- recurrent vomiting since last 3 months. USG abdomen was nor- tinal tract, most commonly in the stomach. The term bezoar is mal. CECT abdomen reported a short segment (4.9 cm) of marked derived from the Arabic ‘badzehr’ or from the Persian ‘padzahr’ circumferential wall thickening (20 mm) involving pylorus of both means ‘to expel potion’ or antidote. Prevalence of bezoar stomach. It was causing marked luminal narrowing with mild is 0.4%. Bezoars are classified in four categories: phytobezoars dilatation of stomach? Mitotic? Inflammatory, multiple enlarged (vegetable matter); trichobezoars (hair balls); pharmacobezoars lymph nodes are noted in mesentery and pre–para aortic region. (tablets or semi-liquid masses drugs); lactobezoars (which are Upper GI endoscopic biopsy reported—chronic gastritis with composed of milk protein) miscellaneous material (clay, stone, very occasional non-caseating epitheloid granuloma in lamina etc.) [1]. propria, no evidence of neoplasia? Crohn’s disease. It may lead to intraluminal obstruction. If endoscopic man- Keeping Crohn’s as diagnosis patient was given mesalamine agement (dissolution therapy) fails, surgical intervention is 400 mg tid by gastrophyscian. But patient didn’t respond so the needed and now it can be managed by the laparoscopy Patient was advised surgical management. Barium meal follow approach. through (BMFT) (Fig. 1), reported multiple hyperplastic polyps Received: April 4, 2018. Accepted: May 5, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy116/5017811 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 S.A. Jain et al. Figure 1: BMFT Film, reported multiple hyperplastic polyps with GOO. with gastric outlet obstruction (GOO). Repeat UGI endoscopy revealed multiple pills (mesalamine) in the stomach with GOO (Fig. 2). Around 40 pills were extracted with the help of flower basket, and then patient underwent laparoscopic management of GOO. Surgical procedure done was laparoscopic gastrojeju- nostomy (Fig. 3). Patient also underwent left and right truncal vagotomy (Fig. 4). DISCUSSION The majority of bezoars are located in the stomach. Four differ- ent types of bezoars: Figure 2: UGI endoscopy showing multiple pills. � Phytobezoar—composed of non-digestible food particles found in fruit and vegetables � Trichobezoar—hair bezoar � Lactobezoar—compact mass of undigested milk concretions � Pharmacobezoar—conglomeration of medications � Others � Trichophytobezoar—mixture of hair, fruit, and vegetable fibres � Diospyrobezoar—persimmons � Dead ascaris—worm bezoars [1] Risk factors for bezoar are cystic fibrosis, intrahepatic cho- lestasis, diabetes, hypothyroidism and renal failure. Edentulous patients with poor mastication of food and patients with psy- Figure 3: Gastrojejunostomy by endostaplers. chiatric illness. Cases of gastroparesis with decreased or absent gastric peristalsis, surgical resection/bypass of the gastric antrum and body, or undergoing a bariatric surgery are particu- larly susceptible to the development of bezoars [2, 3]. Medications reported to cause bezoars include aluminium hydroxide gel, enteric-coated aspirin, sucralfate, guar gum, cholestyramine, enteral feeding formulas, psyllium prepara- tions, nifedipine XL, mesalamine and meprobamate. Bowel hypoactivity, dehydration, and concomitant use of anticholin- ergic and narcotic appear to contribute to the propensity for bezoar formation by aluminium hydroxide gel and Isocal. Insolubility of the carrying vehicle of enteric-coated aspirin and Figure 4: Left and right truncal vagotomy. nifedipine is the setting in which these medications form bezoars. In contrast to non-medication bezoars, pharmacobe- zoars may produce additional symptoms, those related to the reducing or stopping the production of natural chemicals release of their active ingredients [4]. Mesalamine is an anti- which cause inflammation, swelling, tissue damage and diar- inflammatory amino salicylate drug used in the treatment of rhoea. It does not get dissolved in acidic media and there is no ulcerative colitis, as well as Crohn’s disease. It works by dissolution therapy available for it [5]. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy116/5017811 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Pharmacobezoar—a rare case presented 3 Pharmacobezoars can present with symptoms of gastric out- index of suspicion in future clinical encounters may be the best let obstruction, but these bezoars can also produce symptoms way to improve diagnostic sensitivity and accuracy. due to their pharmacologic properties such as epigastric pain or discomfort, dyspepsia, postprandial fullness. As a result, CONFLICT OF INTEREST STATEMENT there is an increased potential for drug intoxication in these patients. Complications such as gastrointestinal bleeding (6%) None declared. or intestinal obstruction or perforation (10%). Our patient actually had benign GOO but due to misleading REFERENCES biopsy of Crohn’s disease and mesalamine therapy lead to formation of pharmacobezoar secondary to GOO. 1. Andru CH, Ponskky JL. Bezoars: classification, pathophysi- One should always rule out GOO before prescribing any medi- ology, and treatment. Am J Gastroenterol 1988;83:476–8. cation especially one which does not get dissolve in acidic media 2. Escamilla C, Robles-Campos R, Parrilla-Paricio P, Lujan- otherwise patients may develop pharmacobezoar and that may Mompean J, Liron-Ruiz R, Torralba-Martinez JA. Intestinal lead to diagnostic dilemma. Patient has to undergo many inves- obstruction and bezoars. J Am Coll Surg 1994;179:285–8. tigations and hospitalization, which increases the cost of treat- 3. Robles R, Parrilla P, Escamilla C, Lujan JA, Torralba JA, Liron ment along with the psychological trauma and many days of R, et al. Gastrointestinal bezoars. Br J Surg 1994;81:1000–1. work loss. So this type of secondary pharmacobezoar though 4. Taylor JR, Streetman DS, Castle SS. Medication bezoars: a lit- rare but it’s a new evolving entity and should be kept in mind as erature review and a report of a case. Ann Pharmacother 1998; one of the cause of recurrent upper gastrointestinal problem. 32:940–6. Rules for suspecting, diagnosing, and properly managing a 5. de Albuquerque IC, Carvalho MA, Betista RR, Formiga pharmacobezoar are highly dependent on the pharmaceutical GJS. Bezoar by mesalamine tablet: cause of intestinal agent or agents involved. Becoming familiar with the sparse obstruction in Crohn’s disease. J Coloproctol (Rio J) 2012;32 data available on pharmacobezoars and maintaining a high (4:422-5). Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy116/5017811 by Ed 'DeepDyve' Gillespie user on 21 June 2018

Journal

Journal of Surgical Case ReportsOxford University Press

Published: May 29, 2018

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