Successful Emergency Endoscopic Treatment of Gastric Outlet Obstruction due to Gastric Bezoar with Gastric Pneumatosis

Abstract

Gastric bezoars are rare and are usually found incidentally. They can sometimes cause severe complications, including gastric outlet obstruction (GOO) or gastric pneumatosis (GP). In cases of bezoars with GP, the optimal treatment strategy has not yet been defined. We report the case of an 89-year-old man with a history of type 2 diabetes mellitus and hypertension who presented to our emergency room with a 2-day history of upper abdominal pain, nausea, and vomiting. Physical examination revealed no rebound tenderness or guarding, and laboratory values revealed no elevation of the serum lactate level. A computed tomography scan of the abdomen showed a dilated stomach with significant fluid collection, GOO, and GP due to a 42 × 40 mm mass composed of fat and air densities. Emergency esophagogastroduodenoscopy revealed two gastric bezoars, one of which was incarcerated in the pyloric region. We used various endoscopic devices to successfully break and remove the bezoars. We used endoscopic forceps and a water jet followed by an endoscopic snare to cut the bezoars into several pieces and remove them with an endoscopic net. Follow-up endoscopy confirmed that the gastric bezoar had been completely removed. As seen in this case, endoscopic treatment may be a safe and viable option for the extraction of gastric bezoars presenting with GOO and GP.

Keywords: Gastric bezoar; Gastric outlet obstruction; Gastric pneumatosis.

Fig. 1.

a Abdominal X-ray showing intramural gas in the stomach wall. Yellow arrows show the intramural gas. b–d A computed tomography scan of the abdomen shows gastric outlet obstruction due to a 42 × 40 mm mass composed of fat and air densities and intramural gas in the stomach wall. It also shows a dilated stomach with significant fluid collection and another 40 × 40 mm mass in the stomach. Yellow arrows show intramural gas and two masses; one of them is incarcerated material at the pyloric region.

Fig. 2.

a Incarcerated bezoar in the pyloric region. b Gastric ulcer causing gastric pneumatosis. We believe this is the entrance of the intramural gas. c Endoscopic view of breaking the bezoar into small pieces with an endoscopic snare. d Endoscopic view of trying to extract the bezoar with the endoscopic forceps. e Endoscopic view of removing the bezoar with the endoscopic net. f After removal of the bezoars from the pyloric region.

Fig. 3.

a, b Follow-up final esophagogastroduodenoscopy revealed spreading patchy redness due to gastric pneumatosis and no remaining bezoar. Patchy redness indicates inflammation of the stomach caused by gastric pneumatosis and general improvement.