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Minimally invasive treatment of duodenal obstruction with acute pancreatitis caused by two large bezoars


 Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University College of Medicine, Seoul, Republic of Korea

Date of Submission18-Jan-2022
Date of Acceptance12-Apr-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Jae Min Lee,
Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University College of Medicine, Seoul
Republic of Korea
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_30_22

PMID: 35915532

  Abstract 


Bezoar without gastrointestinal surgical history occurring simultaneously in the gastric and duodenal lumen is very rare. We report a case of acute pancreatitis due to duodenal obstruction caused by two large bezoars. Two large bezoars were detected in the gastric and duodenal lumen, respectively, on abdominal computed tomography (CT) scan and oesophagogastroduodenoscopy images. Bezoars were crushed and removed using endoscopic devices such as trapezoid basket and lithotripsy handle. After removal of bezoars, blood tests and CT follow-up tests confirmed improvement. In the case of bezoar, which causes duodenal obstruction, it is difficult to administer coke for dissolution, and if it is difficult to perform surgical approach due to old age, an endoscopic treatment using mechanical lithotripsy devices can be an alternative option.


Keywords: Acute pancreatitis, bezoar, endoscopic lithotripsy, trapezoid



How to cite this URL:
Lee KW, Ha YW, Lee JM, Choe JW, Hyun JJ, Lee HS. Minimally invasive treatment of duodenal obstruction with acute pancreatitis caused by two large bezoars. J Min Access Surg [Epub ahead of print] [cited 2022 Aug 17]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=351249





  Introduction Top


In general, gastric bezoars are found in patients with delayed gastric emptying after gastrointestinal surgery. Rarely, it can be observed in patients with normal or accelerated gastric emptying.[1] Simultaneous presence of gastric and duodenal bezoars is very rare. There are very few case reports of acute pancreatitis due to obstruction of the duodenum by a gastric bezoar. We report a case of acute pancreatitis due to duodenal obstruction caused by two large bezoars without surgical history. Endoscopic treatment was performed for the bezoars present in the stomach and in the duodenum.


  Case Report Top


An 85-year-old female patient was admitted to the emergency room owing to abdominal pain and vomiting. She had a history of type 2 diabetes, hypertension and hyperlipidaemia, but no history of any type of operation, including gastrointestinal surgery. Her social history revealed that she enjoyed eating persimmons. On physical examination, she had an acutely ill appearance with a soft abdomen and tenderness in the epigastric area and in the right upper quadrant. Initial laboratory findings revealed that amylase and lipase were 1404 IU/L and 3449 IU/L, respectively. She agreed to all treatments and signed an informed consent relating to the publication. Medical treatments for acute pancreatitis, including intravenous fluids, antibiotics and analgesics, were started, but the abdominal pain did not improve.

On the fourth day of hospitalisation, oesophagogastroduodeno scopy (OGD) was performed for suspected duodenal obstruction. OGD revealed a large bezoar in the second part of the duodenum [Figure 1]a and another large bezoar in the stomach [Figure 1]c. The duodenal bezoar compressing the major ampulla was firmly impacted in the duodenum and was accompanied by multiple duodenal ulcers. Computed tomography (CT) revealed distension of the stomach and the proximal duodenum with mild pancreatic ductal dilatation with two large bezoars [Figure 1]b.
Figure 1: (a) A huge bezoar with linear ulceration in the second part of the duodenum. (b) Computed tomography with contrast-enhanced revealed gastric bezoar (white arrow) with distended stomach and proximal duodenum with mild pancreatic ductal dilatation, obstructed by duodenal bezoar (black arrow). (c) A huge bezoar in the stomach

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Initially, bezoar fragmentation with endoscopic rat-tooth forceps was performed using a gastroscope. However, it was difficult to completely break down the bezoar, as it contained multiple seeds. Therefore, partial endoscopic fragmentation was performed to create enough space for the insertion of an endoscopic snare [Supplement Video 1].[Additional file 1] The duodenal bezoar was successfully cut into smaller pieces and extracted from the duodenum using an endoscopic snare. The gastric bezoar was harder in consistency and larger than the duodenal bezoar. We twisted the wires of a trapezoid basket [Figure 2]a to convert it into a shape similar to that of a snare. After catching the gastric bezoar using the modified trapezoid basket and a lithotripsy handle [Figure 2]b, we proceeded to break the bezoar into smaller pieces [Figure 2]c. The bezoar was successfully cut into several pieces and then removed from the stomach [Figure 2d]. On the eleventh day of hospitalisation, follow-up endoscopy and abdominal CT confirmed that the two bezoars had been completely removed. Epigastric pain and abdominal bloating were resolved.
Figure 2: Endoscopic devices. (a) Trapezoid basket and (b) lithotripsy handle for the endoscopic procedure. Endoscopic fragmentation using (c) the modified trapezoid basket and (d) the lithotripsy handle

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  Discussion Top


The bezoar of the gastrointestinal tract has been reported in several cases in patients such as duodenal diverticulum, gastrointestinal surgery and Rapunzel syndrome. However, in our case report, there were two separate bezoars in the stomach and duodenum that occurred spontaneously without any surgical history. To the best of our knowledge, there have been no case reports of coexisting gastric and duodenal bezoars without anatomical alteration by surgery and causing acute pancreatitis.

Bezoar can cause various symptoms and serious complications such as gastric outlet obstruction, ileus, ulceration and subsequent gastrointestinal bleeding. Removal of a bezoar can be attempted through an endoscope. However, if removal is difficult, chemical dissolution or surgical treatment can be considered. It has been reported that the dissolution of large gastric phytobezoars with nasogastric lavage using Coca-Cola is a safe and rapid procedure.[2] Papain, an enzyme extracted from the Carica papaya plant, was recently reported as an alternative enzymatic therapy for bezoars.[3] Furthermore, laser lithotripsy is another endoscopic treatment option. It utilises the laser to ignite the mini-explosive equipment loaded at the end of a laser fibre to fragment bezoars.[4] However, bezoars vary in size, components and location. Sometimes, the fragmentation of a bezoar can be very difficult. Surgical treatment should be considered in case of difficulty in fragmenting the bezoar or in patients with refractory bezoars.[5]

In the present case, two large (gastric and duodenal) bezoars were observed. The mechanism of bezoar formation can be classified into phytobezoars, trichobezoars, pharmacobezoars and lactobezoars. As we mentioned, she enjoyed eating persimmons, and persimmon seeds were observed during endoscopic bezoar fragmentation. Therefore, it is considered a phytobezoar by persimmon. They were accompanied by the duodenal obstruction, multiple ulcers and acute pancreatitis. Chemical dissolution treatment using Coca-Cola was impossible owing to duodenal obstruction. Moreover, endoscopic laser lithotripsy had a high risk of duodenal perforation. Moreover, surgical treatment was associated with a higher risk because of the advanced age of the patient. Therefore, endoscopic treatment was selected for the removal of the bezoars. However, there is no suitable device for the removal of large gastric bezoars with a stony hard consistency. Many lithotripsy devices such as trapezoid and lithocrush are used for the removal of gallstones. Lithotripsy devices are available in various sizes. Since they can crush hard gallstones, they can also be used to break hard gastric bezoars. The lithotripsy devices are mostly available in the form of four-wire baskets, but adjusting the shape into a two-legged form can make it easier to hold the hard-gastric bezoar, as observed in the present case.

We have reported a case of large bezoar-related acute pancreatitis in a patient without any surgical history. Endoscopic fragmentation of the bezoar causing acute pancreatitis with subsequent duodenal obstruction can be performed safely and effectively using various endoscopic devices.

Acknowledgement

The authors would like to thank the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2021R1H1A2094560) and Korea University Grant (K2110161).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This research was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2021R1H1A2094560) and Korea University Grant (K2110161).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Robles R, Parrilla P, Escamilla C, Lujan JA, Torralba JA, Liron R, et al. Gastrointestinal bezoars. Br J Surg 1994;81:1000-1.  Back to cited text no. 1
    
2.
Ladas SD, Triantafyllou K, Tzathas C, Tassios P, Rokkas T, Raptis SA. Gastric phytobezoars may be treated by nasogastric Coca-Cola lavage. Eur J Gastroenterol Hepatol 2002;14:801-3.  Back to cited text no. 2
    
3.
Dwivedi AJ, Chahin F, Agrawal S, Patel J, Khalid M, Lakra Y. Gastric phytobezoar: Treatment using meat tenderizer. Dig Dis Sci 2001;46:1013-5.  Back to cited text no. 3
    
4.
Mao Y, Qiu H, Liu Q, Lu Z, Fan K, Huang Y, et al. Endoscopic lithotripsy for gastric bezoars by Nd: YAG laser-ignited mini-explosive technique. Lasers Med Sci 2014;29:1237-40.  Back to cited text no. 4
    
5.
Javed A, Agarwal AK. A modified minimally invasive technique for the surgical management of large trichobezoars. J Minim Access Surg 2013;9:42-4.  Back to cited text no. 5
    


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2004 Journal of Minimal Access Surgery
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