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

Abstract

Introduction and importance: Bezoars 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 presentation: A 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 discussion: Bezoars 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.

Conclusion: The 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.

Keywords: Bezoar; Case report; Gastric surgery; Obstruction; Small bowel; Upper endoscopy.

Fig. 1

Abdominal CT showing marked distension of the gastric remnant with anastomotic obstruction caused by a bezoar identified as an intraluminal ovoid mass with a mottled gas pattern (arrow) and collapse of the distal intestinal loops.

Fig. 2

Upper endoscopy revealling a round-shaped hard mass composed of nondigestible material occluding the gastrojejunal anastomosis.

Fig. 3

Bezoar positioned at the efferent intestinal limb causing obstruction. A longitudinal enterotomy was performed 5 cm proximally to the bezoar and it was then milked into the enterotomy orifice and extracted.