CASE REPORT

Successful Treatment with a Combination of Endoscopic Injection and Irrigation with Coca Cola for Gastric -induced Gastric Outlet Obstruction

Chen-Sheng Lin1, Chun-Fang Tung1,2,3*, Yen-Chun Peng1,2,3, Wei-Keung Chow1, Chi-Sen Chang1, Wei-Hsiung Hu2 1Division of , Department of Internal Medicine, and 2Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, and 3National Yang Ming University School of Medicine, Taipei, Taiwan, R.O.C.

We report a case of gastric bezoar-induced gastric outlet obstruction that was successfully treated with a combination of endoscopic injection and irrigation with Coca Cola. A 73-year-old diabetic woman had a history of perforated peptic ulcer and had received pyloroplasty more than 20 years previously. She had been ingesting Pho Pu Zi (Cordia dichotoma Forst. f.) as an appetizer for 1 month. She presented with epigastric pain, nausea, and vomiting. Upper gastrointestinal endoscopy, performed at a local hospital, showed 2 gastric in the stomach, and 1 of them impacted at the pylorus. She was referred to our emergency department for removal of the gastric bezoars that were suspected to be causing gastric outlet obstruction. All attempts at endoscopic removal using a polypectomy snare, biopsy forceps and Dormia basket failed. We then injected Coca Cola directly into the bezoar mass, followed by irrigation with Coca Cola. Follow-up endoscopy was performed the next day, which revealed that the gastric bezoars had dissolved spontaneously. [J Chin Med Assoc 2008;71(1):49–52]

Key Words: bezoars, Coca Cola, endoscopy, gastric outlet obstruction

Introduction sonography, and computed tomography are helpful in the diagnosis of bezoars.3–6 The treatment of gastric Bezoars are collections or concretions of indigestible bezoars can be conservative (via endoscopic removal) or animal or vegetable material that accumulate and coa- surgical. The efficacy of nasogastric lavage with Coca lesce in the gastrointestinal tract, usually the stom- Cola for dissolution of gastric bezoars and direct intra- ach.1–3 Gastric bezoar formation occurs in patients with bezoar infusion endoscopically has been reported in altered gastric physiology, impaired gastric emptying Greece, Japan and South Korea.4,6,12,13 Herein, we and/or reduced acid production. Poor mastication report the case of a patient with gastric bezoars who was and ingestion of large quantities of indigestible solids successfully treated with a combination of endoscopic may precipitate bezoar formation.4–7 The reported injection and irrigation with Coca Cola. incidence of bezoars is 0.4%,8 although the true inci- dence is unknown. Symptoms of gastric bezoars are usually vague and nonspecific, including nausea, vom- Case Report iting, epigastric pain, foul breath, halitosis, and early satiety.4,6 Bezoars usually form in the stomach, but can In November 2004, a 73-year-old woman was referred pass into the small intestine, where they occasionally to our emergency department because of epigastric pain, cause obstruction.5,9–11 Endoscopy, barium studies, nausea, and vomiting. She had a history of hypertension,

*Correspondence to: Dr Chun-Fang Tung, Department of Emergency Medicine, Taichung Veterans General Hospital, 160, Section 3, Chung-Kang Road, Taichung 407, Taiwan, R.O.C. E-mail: [email protected] ● Received: June 6, 2007 ● Accepted: September 7, 2007

J Chin Med Assoc • January 2008 • Vol 71 • No 1 49 © 2008 Elsevier. All rights reserved. C.S. Lin, et al diabetes mellitus, and perforated peptic ulcer status bezoar masses, infusing the Coca Cola in multiple post pyloroplasty more than 20 years ago. She had directions. The residual content of the can of Coca been ingesting Pho Pu Zi (Cordia dichotoma Forst. f.) Cola, about 100 mL, were then irrigated into the stom- as an appetizer for 1 month. Upper gastrointestinal ach. The total procedure required about 60 minutes. endoscopy, performed at a local hospital, showed That night, the patient was treated with intravenous 2 gastric bezoars, with 1 of them impacted at the metoclopramide 10 mg every 8 hours, and was given pylorus. With suspected gastric bezoar-induced gastric another can of Coca Cola to drink. The next morning, outlet obstruction, she was referred to our hospital repeated endoscopy showed that the gastric bezoars for bezoar removal. had dissolved completely, and the stomach, pylorus On physical examination, she appeared acutely ill, and duodenal bulb were clear (Figure 2). At follow- but with stable vital signs (blood pressure 175/ up 1 year and 6 months later, upper gastrointestinal 82 mmHg, pulse rate 93/min, respiratory rate 18/min). endoscopy revealed no bezoar recurrence. Her abdomen was soft, but showed tenderness over the epigastric area. Laboratory data included white blood cell count 12,700/mL, with 74.4% neutrophils, Discussion 19.3% lymphocytes and 4.7% monocytes, hemoglobin 14.4 g/dL, platelet count 447,000/mL, blood glucose Bezoars are collections or concretions of indigestible 156 mg/dL, blood urea nitrogen 16 mg/dL, creatinine foreign material that accumulate and coalesce in the 0.8 mg/dL, sodium 143 mmol/L, and potassium gastrointestinal tract.1 Most bezoars reside in the stom- 4.0 mmol/L. ach but may be encountered elsewhere in the gas- Upper gastrointestinal endoscopy was performed trointestinal tract, including the rectum and even the using a standard forward-viewing endoscope with esophagus.2 Bezoars are classified into 4 main types, a 2.8-mm diameter accessory working channel (GIF- according to the materials of which they are composed: XQ240; Olympus, Tokyo, Japan). It showed 2 gastric phytobezoars, trichobezoars, medication bezoars, and bezoars, the larger 1 in the body of the stomach, and lactobezoars. The most common type is phytobezoars, the other impacted at the pylorus, inducing gastric which consist of indigestible fruit, vegetable fiber, skin outlet obstruction (Figure 1). All initial attempts at or seeds. Phytobezoars are classically found in adults endoscopic removal using a polypectomy snare, biopsy with a history of previous gastric surgery, conditions of forceps and Dormia basket failed. The surfaces of reduced gastric acidity, poor gastric mixing, or delayed the gastric bezoars were slightly damaged by the motility. Trichobezoars, or hairballs, are a mass of hairs mechanical effects of the endoscopic procedure. and/or decaying food material, usually found in chil- We then decided to use Coca Cola to dissolve the dren and young females with psychiatric disorder or bezoars. The contents of 1 can of Coca Cola (Coca mental retardation. Medication bezoars consist of Cola Co., Taiwan) were drawn into a 30-mL syringe. undigested tablets or semi-liquid drugs. Lactobezoars The tip of a 22G injector was used to inject the Coca are frequently found in low-birth-weight or premature Cola through the accessory working channel into the neonates fed a highly concentrated formula within the

A B

Figure 1. Endoscopic view of gastric bezoars: (A) a large yellowish bezoar in the body of the stomach; (B) 1 bezoar impacted the pylorus, causing gastric outlet obstruction.

50 J Chin Med Assoc • January 2008 • Vol 71 • No 1 Gastric bezoars treated with Coca Cola

A B

Figure 2. Post treatment endoscopic view of: (A) the body of the stomach; (B) deformity of the pylorus and duodenal bulb. first weeks of life.3 Bezoars usually form in the stom- method. Barium studies, sonography, and computed ach, but can pass into the small intestine, where they tomography are also helpful in the diagnosis.3–6 occasionally cause obstruction. Contributing factors for The treatment of gastric bezoars can either be con- obstruction include dysmotility of the gastrointestinal servative or surgical. Conservative treatment is usually tract, dehydration, and diabetes mellitus. based on endoscopic fragmentation and extraction, Gastric bezoar formation occurs in patients with dissolution with enzyme or medicine. Surgical treatment altered gastric physiology, impaired gastric emptying is via laparotomy or laparoscopy after a failed conser- and/or reduced acid production. This is usually caused vative procedure.4–6,11,15–17 The efficacy of nasogas- by previous gastric surgery, such as partial gastrec- tric lavage using Coca Cola for dissolution of gastric tomy, or pyloroplasty, but may be caused bezoars and direct endoscopic intrabezoar infusion has by or gastric outlet obstruction. Poor been reported in Greece, Japan and South Korea.4,6,12,13 mastication and ingestion of large quantities of indi- Ladas et al lavaged Coca Cola through a nasogastric gestible solids may precipitate bezoar formation.4–7 tube to dissolve a gastric phytobezoar.6 However, It is customary in certain areas of Taiwan to eat the they recommended that a large volume of the beverage, pickled fruit of the Pho Pu Zi (Cordia dichotoma nearly 3 liters, be used, and the lavage was performed Forst. f.) as an appetizer. The sticky pulp and indi- over 12 hours. gestible seeds of this fruit can form a phytobezoar if In contrast, we injected Coca Cola easily into the ingested excessively.7 The reported incidence of bezoars bezoars, and the patient only needed to drink 1 can is 0.4%,8 although the true incidence is unknown. In of Coca Cola afterwards. The combination of endo- patients with symptoms after antrectomy, the incidence scopic injection and oral intake of Coca Cola seemed is much higher, in the range of 10–25%.14 Predisposing to be rapidly effective and safe.4,13 Lee et al reported factors for gastric bezoar formation in this case included 2 cases of phytobezoars that were treated by oral diabetes mellitus, a history of pyloroplasty, and ingestion administration of Coca Cola.18 These 2 patients drank of Pho Pu Zi for 1 month. 700–800 mL of Coca Cola daily, and after 2 months, The symptoms of gastric bezoars are usually vague complete dissolution of bezoars was achieved. Oral and nonspecific, depending on the size, location, and administration of Coca Cola for at least 2 months was degree of disturbance of gastric physiology. Symptoms not suitable for our patient because she was diabetic. may include nausea, vomiting, epigastric pain, foul Besides, some types of phytobezoars, such as diospy- breath, halitosis, and early satiety.4,6 Gastric outlet robezoars, are considered to be harder than other obstruction, gastrointestinal tract bleeding, perfora- types, and complete dissolution of bezoars may not be tion, peritonitis, and intestinal obstruction may also achieved by only drinking Coca Cola in such a case. be complicating factors.5,9–11 Oral intake and endoscopic injection of Coca Cola Diagnosis of gastric bezoars requires a high index of seemed to be the best approach, which proved to be suspicion. There is no classical presentation based on easy, rapidly effective, inexpensive and safe in our patient. history or physical or radiographic findings. Upper gas- This form of gastric bezoar dissolution should be trointestinal endoscopy is the most sensitive diagnostic studied prospectively in a series of patients.

J Chin Med Assoc • January 2008 • Vol 71 • No 1 51 C.S. Lin, et al

The mechanism of Coca Cola dissolution is not 5. Zamir D, Goldblum C, Linova L, Polychuck I, Reitblat T, well understood. Acid is important in digesting fiber. Yoffe B. Phytobezoars and trichobezoars: a 10-year experience. J Clin Gastroenterol 2004;38:873–6. Coca Cola, which has a pH of 2.6, may be a substi- 6. Ladas SD, Triantafyllou K, Tzathas C, Tassios P, Rokkas T, 4,6 tute for normal gastric acidity. In addition, it has Raptis SA. Gastric phytobezoars may be treated by nasogastric been suggested that the NaHCO3 contained in Coca Coca Cola lavage. Eur J Gastroenterol Hepatol 2002;14:801–3. Cola has a mucolytic effect.12 Furthermore, penetra- 7. Yin WY, Lin PW, Huang SM, Lee PC, Lee CC, Chang TW, Yang YJ. Bezoars manifested with digestive and biliary obstruc- tion of CO2 bubbles into the surface of bezoars may tion. Hepatogastrology 1997;44:1037–45. digest the fibers of concretion. The combined action 8. Kadian RS, Rose JF, Mann NS. Gastric bezoars: spontaneous of NaHCO3 and CO2 as well as unknown agents in resolution. Am J Gastroenterol 1978;70:79–82. Coca Cola are considered the important factors in 9. Dwivedi AJ, Chahin F, Agrawal S, Patel J, Khalid M, Lakra Y. Gastric phytobezoar: treatment using meat tenderizer. Dig Dis dissolving bezoars. Sci 2001;46:1013–5. In conclusion, we have reported a case of gastric 10. Wadlington WB, Rose M, Holcomb GW Jr. Complications bezoar-induced gastric outlet obstruction that was of trichobezoars: a 30-year experience. South Med J 1992; successfully treated with a combination of endoscopic 85:1021–2. 11. Chou NH, Chou NS, Mok KT, Liu SI, Wang BW, Hsu PI, injection and irrigation with Coca Cola. This method Tsai CC, et al. Intestinal obstruction in patients with previous proved to be rapidly effective, inexpensive and safe. laparotomy for non-malignancy. J Chin Med Assoc 2005;68: The classification, presenting symptoms, diagnostic 327–32. methods, and treatment of bezoars were discussed. 12. Kato H, Nakamura M, Orito E, Ueda R, Mizokami M. The first report of successful nasogastric Coca Cola lavage treatment for The ultimate goal of bezoar treatment is removal and bitter persimmon phytobezoars in Japan. Am J Gastroenterol prevention of recurrence. Thus, educating patients 2003;98:1662–3. about which causative fruits or vegetables to avoid and 13. Chung YW, Han DS, Park YK, Son BK, Paik CH, Jeon YC, proper mastication would be beneficial in preventing Sohn JH. Huge gastric diospyrobezoars successfully treated by oral intake and endoscopic injection of Coca Cola. Dig Liver the recurrence of bezoars. Dis 2006;38:515–7. 14. Sandler RS, Todisco A. Miscellaneous diseases of the stomach. In: Yamada T, Alpers DH, Laine L, Owyang C, Powell DW, eds. Gastroenterology. Philadelphia: Lippincott Williams & Wilkins, References 1999:1549–60. 15. Walker-Renard P. Update on the medical management of 1. Hamilton K, Polter D. Foreign bodies and bezoars. In: phytobezoars. Am J Gastroenterol 1993;88:1663–6. Feldmann M, Scharschmidt BF, Sleiseger MH, eds. Gastro- 16. Gaia E, Gallo M, Caronna S, Angeli A. Endoscopic diagnosis intestinal and Liver Disease. Philadelphia: Saunders, 1998:331–5. and treatment of gastric bezoars. Gastrointest Endosc 1998; 2. Byrne WJ. Foreign bodies, bezoars, caustic ingestion. Gastrointest 48:113–4. Endosc Clin North Am 1994;4:99–104. 17. Balm ME, Lichtenstein GR. A new endoscopic technique for 3. Ripolles T, Garcia-Aguayo J, Martinez MJ, Gil P. Gastrointestinal removal of gastric phytobezoars. Gastrointest Endosc 2000;52: bezoars: sonographic and CT characteristics. AJR Am J 404–8. Roentgenol 2001;177:65–9. 18. Lee HJ, Kang HG, Park SY, Yi CY, Na GJ, Lee TY, Kim SH, 4. Sechopoulos P, Robotis JF, Rokkas T. Gastric bezoar treated et al. Two cases of phytobezoars treated by administration of endoscopically with a carbonated beverage: case report. Coca Cola by oral route. Korean J Gastroenterol 2006; Gastrointest Endosc 2004;60:662–4. 48:431–3.

52 J Chin Med Assoc • January 2008 • Vol 71 • No 1