Gastroenterology Insights 2016; volume 7:6808 A giant gastric bezoar in patients with delaying gastric emptying (such as those with diabetic gastroparesis, mixed Correspondence: Jin Yu Chieng, Department of Billroth II stomach: connective tissue disease, or hypothyroidism.2- Medicine, Faculty of Medicine and Health a case report on successful 4 Other predisposing conditions are inade- Science, Putra University of Malaysia, 43400 endoscopic removal via quate fluid intake leading to dehydration, and Serdang UPM, Selangor, Malaysia anatomic abnormalities such as diverticula or Tel.: +60.006.016.8580155. repeated fragmentation gastric outlet obstruction.1,2 E-mail: [email protected] and dissolution technique Most of the patients are fairly asymptomatic Key words: Anemia; Bezoar; Oesophago-gastro- initially. Abdominal pain (70%), nausea and negating the need for surgical duodenoscopy; OGDS; Ulcer. vomiting (64%), and early satiety are the main intervention 1,2,4,5 clinical symptoms. Gastric bezoars may Contributions: the authors contribute equally. result in peptic ulcer disease from pressure Jin Yu Chieng,1 Shiaw Hooi Ho,2 necrosis,6 and subsequent gastrointestinal 2 Conflict of interest: the authors declare no poten- Khean Lee Goh bleeding as well as gastric outlet obstruction.7,8 tial conflict of interest. 1Department of Medicine, Faculty A wide variety of therapeutic options have of Medicine and Health Science, Putra been reported. Medical treatment includes dis- Received for publication: 29 July 2016. University of Malaysia, Selangor; solution with ingestion of cellulose, papain, or Accepted for publication: 12 August 2016. 2 N-acetylcysteine.1,2,5,9-13 Ingestion of carbonat- Department of Medicine, University This work is licensed under a Creative Commons ed beverage Coca-Cola has been successfully of Malaya, Kuala Lumpur, Malaysia Attribution NonCommercial 4.0 License (CC BY- 4,14-16 used to dissolve bezoars. Endoscopic NC 4.0). management includes mechanical fragmenta- tion of the bezoar using water jet with subse- ©Copyright J. Yu Chieng et al., 2016 Abstract quent extraction, a drill device, tripod forceps, Licensee PAGEPress, Italy polypectomy snare plus diathermy, mechanical Gastroenterology Insights 2016; 7:6808 lithotripter, or Dormia basket.2,3,17 Surgical doi:10.4081/gi.2016.6808 A 76-year-old gentleman presented with intervention would be indicated if endoscopic only anemia. He had a history of perforated duode- removal fails. nal ulcer six years ago, with Billroth II repair We report a male patient with a history of 2 performed. A large gastric bezoar (8×6 cm ) gastric surgery presented with peptic ulcer dis- as outpatient. with a clean base ulcer at the anastomotic ease secondary to a giant gastric bezoar.use During the first OGDS attempt, we found junction was found during the initial oesopha- that the bezoar was too hard to be segmented go-gastro-duodenoscopy (OGDS). Rapid ure- by using biopsy forcep/baskets/polypectomy ase test was negative. He presented with mele- snare/tripod forceps/Argon plasma coagulation na during the subsequent follow up (OGDS Case Report alone. Only superficial pieces were removed. showed a Forrest Ib prepylori ulcer). We have After review the literature, decision had successfully removed the gastric bezoar with A 76-year-old gentleman was referred from been made to try to remove the gastric bezoar dissolution therapy initially (injection of coke- Healthcare Clinic for iron deficiency anemia by endoscopic fragmentation techniques and cola into the bezoar, followed by drinking 325 with positive fecal occult blood test. The dissolution therapy. In total, 5 sections of TM mL Coca-Cola twice daily), followed by four patient had a history of perforated duodenal OGDSs had been performed to remove the attempts of OGDS with endoscopic fragmenta- ulcer six years ago, with laparotomy repair bezoar under sedation (intravenous midazo- tion. Histopathology reported as degenerated (Billroth II) performed. He had mild epigastric lam/fentanyl). vegetable matter, acellular debris mixed with commercialdiscomfort. His bowel habits had never During the second OGDS attempt, we inject- scattered fungal and bacterial colonies, which changed. He did not report any loss of weight ed, via variceal needle, inside the bezoar 200 was compatible with bezoar. Follow-up OGDS or appetite. He denied of taking any traditional mL of Coca-Cola. The patient was instructed to showed complete clearance of the bezoar. or herbal medicine, nor the analgesic or drink at least one 325ml can of Coca-Cola twice TM Coca-Cola ingestion should be considered as steroid abuse. He denied of smoking. He did daily. initial treatment as it is non-invasive,Non and it not have any history of malaenic stool or During the third review, the patient claimed enables further successful endoscopic frag- hematemesis initially. He was clinically mild he had passing out malaenic stool. mentation. pallor. Laboratory data showed iron deficiency Hemoglobin level was 9.2 g/dL. OGDS reviewed anemia (hemoglobin level 9.1 g/L with low a bleeding anastomotic junction ulcer (Forrest mean cell volume and low mean cell hemoglo- class Ib), with the gastric bezoar. The bleeding bin, together with low serum iron, ferritin and had been successful secured by combination of Introduction transferrin saturation level). adrenaline injection and heater probe applica- A large gastric bezoar (about 8×6 cm2, of tion. He was warded for blood transfusion A bezoar is an indigestible mass of material, hard consistency) with an anastomotic junc- together with infusion proton pump inhibitor. such as hair, food, seeds, that other ingested tion ulcer (Forrest class III, with clean base) He was discharged well three days later. substances found in the gastrointestinal tract.1 was diagnosed during the oesophago-gastro- During the subsequent OGDSs, the anasto- Gastric bezoars are rare with estimated inci- duodenoscopy (OGDS) (Figure 1). Rapid ure- motic junction ulcer was found to be healed. dence about 0.4% on upper endoscopy.2 ase test was negative. Biopsies of the ulcer We noticed that the bezoar had become much Gastric bezoars usually result from inges- were taken, and reported as chronic active gas- softer, and easier to be segmented into small tion of indigestible material in patients with tritis with intestinal metaplasia histopatholog- pieces by using hot polypectomy snare. The impairment in the gastric motility or digestion, ically. At the time of diagnosis, no attempt was bezoar had been completely removed by using which could be due to previous gastric surgery made to remove or mechanically disrupt the a therapeutic scope with a roth net during the (such as Billroth I or II gastrectomy) or in the bezoar. Proton pump inhibitor was prescribed fourth OGDS attempt (Figure 2). [Gastroenterology Insights 2016; 7:6808] [page 43] Case Report Histopathology reported as mainly degenerat- ed vegetable matter, acellular debris mixed with scattered fungal and bacterial colonies, which was compatible with bezoar. Follow-up OGDS showed complete clearance of the bezoar (Figure 3). Subsequent hemoglo- bin levels were stable then. The interval of time from the initiation of treatment to endoscopic confirmation of bezoar clearance was 12 weeks. Discussion Figure 1. An endoscopic view of the gastric bezoar in the patient, with a prepyloric ulcer (Forrest class III with clean base). This patient had previous history of Billroth II surgery, which was a factor for formation of gastric bezoar. He presented to us with iron deficiency anemia, and the diagnostic OGDS shown peptic ulcer disease, which developed bleeding later on. This could be due to pres- sure ulcer as the Rapid urease test was nega- tive. Lee and colleagues had published a series with 17 patients, which shown combination only treatment with dissolution therapy and endo- scopic fragmentation technique were able to dissolve nearly all bezoars (16/17), while disso- lution therapy alone was successful in only 25% of the cases.18 In our case, we successes use to soften the gastric bezoar by ingestion of Coca-Cola, and to segment the bezoar into smaller pieces using hot polypectomy snare, followed by removal with roth net. Coca-Cola ingestion is a cheap, easy-to-per- form and safe procedure that can be accom- plished at any endoscopy unit. The mechanism of bezoar dissolution by Coca-Cola has not been thoroughly explained. It is believed that Figure 2. The fragments of the gastric bezoar removed from the stomach. the sodium bicarbonate in Coca-Cola has a mucolytic effect, and the carbon dioxide bub- commercial bles may penetrate into the bezoar, leading to digestion of the fibers. Coca-Cola’s low pH level (close to normal gastric secretions’ pH level) is important for the digestion of the fiber by acidifying the gastric content. Coca-ColaNon diminishes the size and softens the hard con- sistency of the bezoar, thus facilitating the dis- solution by hot polypectomy snare. Conclusions This study shows a successful removal of a large gastric bezoar with dissolution therapy using Coca-cola, followed by endoscopic frag- mentation techniques. Coca-cola ingestion should be considered as initial treatment as it is non-invasive, and it enables further success- ful endoscopic fragmentation. Figure 3. After treatment, there was complete resolution of the gastric bezoar. [page 44] [Gastroenterology Insights 2016; 7:6808] Case Report obstruction. Aust N Z J Surg 1994;64:187- er. Pharmacotherapy 2007;27:299-302. References 9. 14. Kato H, Nakamura M, Orito E, et al. The 8. Leung E, Barnes R, Wong L. Bezoar in gas- first report of successful nasogastric coca- 1. 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