case report Seaweed Bezoar with Severe Gastric Pouch Dilation Post Roux-en-Y Gastric Bypass
Mark E. Mahan1, Benjamin Rutta2, Ryan D. Horsley1*
1Geisinger
Community Medical Center, Scranton, PA, USA
2Geisinger Commonwealth School of Medicine, Scranton, PA, USA
*Corresponding author: Ryan D. Horsley, Department of MIS & Metabolic Surgery, Geisinger Community Medical Center, 1800 Mulberry St, Scranton, PA 18510, USA. Tel: +15707032070; Fax: +15707037631; Email: rdhorsley@geisinger.edu
Received Date: 29 May, 2018; Accepted Date: 06 June, 2018; Published Date: 14 June, 2018
Citation: Mahan ME, Rutta B, Horsley RD (2018) Seaweed Bezoar with Severe Gastric Pouch Dilation Post Roux-en-Y Gastric Bypass. Arch Surg Clin Case Rep: ASCR-104. DOI: 10.29011/ASCR-104/100004
1. Case Report
A 61-year-old female with past medical history significant for peptic ulcer disease, open Roux-en-Y gastric bypass, performed over 20 years prior, and recurrent incisional hernia repair presented to her local Emergency Department (ED) with chief complaint of epigastric pain associated with nausea, vomiting, anorexia and constipation. Before presenting to the ED, she was evaluated by her primary care physician and prescribed Sucralfate, with presumed ulcer exacerbation. Despite medical therapy, her pain continued to progress throughout the week. On questioning it was found her discomfort began after consumption of a large seaweed salad 10 days prior.
2. Keywords: Bezoar; Gastric Bypass; Roux-en-Y Gastric Bypass; Seaweed Bezoar
3. Case
Abdomen and pelvis
Computed Tomography (CT) with Intravenous (IV) contrast, revealed a severely
dilated, 9.54 x 6.85 cm gastric pouch, containing retained debris extending
into the gastrojejunostomy (Figures 1 & 2).
Findings were deemed suspicious for obstruction due to retained food
debris/bezoar with associated inflammatory changes. An anastomotic ulcer could
not be evaluated due to retained debris. There were no definitive findings to
suggest perforation.
The patient was
admitted to the hospital and underwent an upper endoscopy. The lower third of
the esophagus was found to be moderately tortuous, with a dilated gastric pouch
containing a bezoar with large amount of food debris (Figure
3). The pouch-to-jejunum limb measured approximately 7cm from the
anastomosis to Z-line. Food debris was cleared using biopsy forceps, roth nets,
and an Edlich gastric lavage kit; using greater than 3500cc of sterile water.
The patient tolerated the procedure well. She was started on a full liquid diet
and discharged the following day.
Although gastric bezoars are uncommon, incidence is increased in those who have undergone a gastric reducing procedure [1]. Bezoars of the alimentary tract are most commonly composed of cellulose products (phytobezoar) [2]. However, after bariatric procedures bezoars have been documented to include unusual compositions including but not limited to: sutures, staples, and cardboard [3]. Bezoar formation is hypothesized to occur secondarily to altered anatomy, subsequent reduction in gastric motility, loss of pyloric function and hypoacidity [2]. Threshold for CT imaging should be low in those with history of bariatric surgery, regardless of date, whom present with dysphagia and epigastric discomfort [4]. For those in whom gastric bezoar is suspected, upper endoscopy is a highly effective and safe therapeutic intervention. We recommend upper endoscopy as the initial therapeutic modality of choice for those with gastric bezoar following Roux-en-Y gastric bypass.
4. Disclosures
All authors included have no associations that may be a conflict of interest in relation to this article.
5. Acknowledgements
All authors
included have received no financial or other substantive assistance for the
funding of this work.
Figure 1: Abdominal CT with IV contrast showing
gastric-pouch dilation (coronal plane).
Figure 2: Abdominal CT with IV contrast showing
gastric-pouch dilation (axial plane).
Figure 3: Gastric Bezoar above Gastrojejunostomy as
visualized during endoscopy.