Bezoar as a cause of gastric perforation in young female patient: A Case Report

Palwasha Gul 1, Islah Ud Din 2, Nosheen Kanwal 3

  1. Fellow body imaging, Shaukat Khanum memorial hospital and research center Lahore.
  2. Consultant Radiologist, Shaukat Khanum memorial hospital and research center Lahore.
  3. Radiology resident, Shaukat Khanum memorial hospital and research center Lahore.

Corresponding Author: Palwasha Gul, Department of Radiology, Shaukat Khanum memorial hospital and research center Lahore. Contact Author.
Submission: Feb 19, 2020
Acceptance: May 03, 2020
Publication: May 11, 2020

© Author(s) (or their employer(s) 2020. Re-use permitted under CC BY. No commercial re-use. Published by Pak J Surg Med. 

Article Citation: Gul P, Din IU, Kanwal N. Bezoar as a cause of gastric perforation in young female patient: A Case Report. Pak J Surg Med. 2020;1(2):118-121. 10.37978/pjsm.v1i2.178

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Abstract

Introduction: Bezoars are rare accumulations of indigestible contents within the gastrointestinal tract. These are commonly found in patients with previous psychiatric illness, learning disabilities, and gastric surgery. Computed tomography (CT) is the non-invasive imaging modality of choice as it can not only diagnose but recognize associated complications as well.
Case Report: We present a case of a young 16 years old female who presented with nausea, dull abdominal pain, and distension. She underwent a Contrast-enhanced CT scan and was diagnosed as a case of gastric bezoar with gastric perforation and frank pneumoperitoneum. The patient underwent exploratory laparotomy and repair of the stomach. Per operative, findings were consistent with trichobezoar. The patient recovered well after surgery.
Discussion: Bezoar is an accumulation of partially digested foreign material in the gastrointestinal (GI) tract. Bezoar can occur in any part of GIT, however, are most common in the stomach. Multiple risk factors are recognized however can occur without the risk factor. Bezoars are classified into several main types. Proper clinical history, examination, and imaging can play an important role in its diagnosis. 
Conclusion: Nonspecific abdominal pain in young female patients with a psychiatric disorder can result from uncommon causes such as bezoars and is important for clinicians and radiologists to be aware of this uncommon entity. 
Keywords: bezoar, gastric, pneumoperitoneum.

Introduction

Bezoars are uncommon findings in the gastrointestinal tract and are composed of a wide variety of materials, that are indigestible. Depending upon components different types of bezoars are identified trichobezoar, phytobezoar, pharmacobezoar and lactobezoar. By far phytobezoar and tricobezoar are most common.[1, 2] Trichobezoars are most commonly seen in psychiatric patients. When the tail of the trichobezoar extends some distance through the small bowel it is called Rapunzel syndrome.[1-3]
Trichobezoar consists of hair and commonly seen in females who chew and swallow their hair. It is usually confined to the stomach. Phytobezoars consists of poorly digested fruits, inadequate chewing or previous gastric surgery are the predisposing factors and can present with small bowel obstruction.[1]
Seed bezoars are a subtype of phytobezoars, caused by undigested vegetable seeds or fruit pits. Contrary to other types, seed bezoar is found in the rectum with no predisposing factors, a fact that suggests a different patho-physiological process.[3] Symptoms and management can be variable depending upon the type of bezoar.The presence of bezoar can be indicated from plain radiography however recent studies show that CT scan is more helpful in diagnosing bezoar.[2]
We present a case of a young 16 years old girl who was diagnosed as a case of gastric bezoar on Contrast-enhanced CT (CE CT) abdomen and pelvis.

Case Report

A 16 years old female presented to the diagnostic center of Shaukat Khanum memorial hospital and research center with complaints of nausea, dull abdominal pain, and distension for 48 hours. On examination, the abdomen was tender, bowel sounds were absent. Her mother further gave a history of early satiety and anorexia. The patient’s mother told us that she has observed her daughter chewing her hair at times. On workup her CBC, RFTs, and LFTs were within the normal range. Previous sonographic reports showed the possibility of left hemi-abdominal mass. Her contrast-enhanced CT examination was performed on a 160 slice canon CT scanner on an emergent basis, which showed frank pneumoperitoneum [Fig 1a]. The stomach was distended with mottled air lucencies suggesting trichobezoar [Fig 1b]. CT was reviewed in multiple planes and gastric perforation with a defect in greater curvature was discovered along with mild abdominal free fluid. The rest of the abdominal organs were unremarkable. After urgent reporting, the informed consent was obtained from mother of child. The patient underwent exploratory laparotomy. Per operative, findings were consistent with trichobezoar and the bezoar was removed along with primary gastric repair with 2/0 vicryl sutures in two layers. Abdomen was lavaged with copious saline and closed in single layer Proline with insitu 28 fr drain[Fig 2]. The patient recovered well after surgery and discharged on fifth day. She was healthy on follow up visits and  was referred for psychiatric counseling.

Figure 1: Axial (a) and coronal (b) reconstructed images of contrast enhanced CT showing Pneumoperitoneum with air outlining falciform ligament (a). Stomach is distended showing internal mottled appearance suggesting gastric bezoar (a,b).

Figure 2: Surgical removal of conglomeration of hair (gastric bezore), conformation to shape of stomach

Discussion

The word bezoar can trace its origins to Arabic (“bazahr”) and Persian (“pad-zahr”), has been known to human kind for ages.[4, 5] Bezoar was believed to have medicinal properties and was hailed as catholicon.[6] A bezoar is accumulation of partially digested or non-digested foreign material in the gastrointestinal (GI) tract.[3, 5] They can occur anywhere from the esophagus to the rectum, however, they predominate the stomach.[3, 7] Females in any age group are common patients.[7] Trichobezoars are frequently seen in women, with only few cases reported in males and is common among ages of 13–20 years.[8, 9] Certain risk factors ,identified in adults include gastric surgeries, achlorhydia, chronic illnesses like diabetes (and other endocrinopathies) chronic gastropresis and patients on mechanical ventilation. Trichobezoars are frequent in children ,psychiatric patients and mentally retardates.[5] The symptomatology of bezoar varies depending upon its location in gastro-intestinal tract but the most common presentation is with signs and symptoms of intestinal obstruction.[8] On examination, a tender mass may be palpable in abdomen but this is not a definite occurance.[8, 9]
Investigations include abdominal radiographs which however are of limited use and can only help in diagnosis of bowel obstruction (if present). Sonography is of limited sensitivity in diagnosing gastric bezoar as in our case.[1] Contrast studies of the gastrointestinal tract and computed tomography scan are gold standard. In our patient previous ultrasound raised suspicion of left hemi-abdominal mass however it was inconclusive. CT scan proved to be the diagnostic modality of choice and revealed trichobezoar causing gastric distension and perforation. Multiple studies have confirmed the role of CT scan in evaluating diagnosing bezoars and also picking up obstruction.[11, 12] CT scan identifies bezoar as, well-defined oval intra-luminal mass with air bubbles, identifies its level of accumulation and presence or absence of GI obstruction. Gastric food particles can at times be confusing to differentiate from bezoar for an inexperienced radiologist. Small bezoars appear as round, floating and of lower density then food residues unlike large bezoars which show internal air locules and tend to fill lumen.
Barium studies are indicated, however it may limit endoscopic visualization. Upper GI Endoscopy also remains investigation of  choice in long standing cases as it can be used both for diagnostic and therapeutic purposes.[13] GI bezoars are uncommon cause of bowel obstruction and a rarely reported cause of gastric perforation, accounting for only 4 % of all admissions for small-bowel obstruction.[14] GI obstruction is more commonly seen in Phytobezoars. Apart from obstruction, prolong history of gastric bezoar can also lead to ulceration and perforation. It is due to pressure necrosis of stomach, weakening the stomach wall and ultimately perforation which is preventable if diagnosed and treated early. Many studies have reported perforation in bezoar only picked up during surgical intervention as in our patient.[15] Hence early diagnosis is imperative for early cure and to prevent complications. It is worthwhile that Ripollés T et al reported that concurrent gastric and intestinal bezoar was found in 53% of their subjects hence whole GI track should be visualized pre and peroperatively.[1]

Conclusion

Bezoar should be considered in differential diagnosis in any young female, presenting with pain abdomen , S/S of intestinal obstruction with psychiatric disorders. CT scan is gold standard for early diagnosis and with prompt treatment,many complications can be prevented. These bezoar induced gastric perforations can be managed by primary repair with good results.

References

  1. Ripollés T, García-aguayo J, Martínez MJ et-al. Gastrointestinal bezoars: sonographic and CT characteristics. AJR Am J Roentgenol. 2001;177 (1): 65-9. Available from: doi: 10.2214/ajr.177.1.1770065
  2. Ertugrul I, Tardum Tardu A, Tolan K, Kayaalp C, Karagul S, Kirmizi S. Gastric bezoar after Roux-en-Y gastric bypass for morbid obesity: A case report. Int J Surg Case Rep. 2016;23:112-5. Available from: doi: 10.1016/j.ijscr.2016.04.008.
  3. Manatakis DK, Acheimastos V, Antonopoulou MI, Balalis D, Korkolis DP. Gastrointestinal seed bezoars: a systematic review of case reports and case series. Cureus.;11(5). Available from: doi: 10.7759/cureus.4686
  4. bezoar (n.) [Internet].Online Etymology Dictionary. [cited 2020 Apr 25]. Available from: https://www.etymonline.com/word/bezoar
  5. Eng K, Kay M. Gastrointestinal bezoars: history and current treatment paradigms. Gastroenterol Hepatol (N Y). 2012;8(11):776-8.
  6. Do Sameiro Barroso M. The bezoar stone: a princely antidote, the Távora Sequeira Pinto Collection-Oporto. Acta Med Hist Adriat. 2014;12(1):77-98. PMID: 25310610.
  7. Chacko A, Masters BI, Isles A. Giant Gastric Bezoar Complicating Congenital Esophageal Atresia Repaired by Gastric Interposition-A Case Report. Front Pediatr. 2017;5:98. Available from: doi: 10.3389/fped.2017.00098.
  8. Coufal NG, Kansagra AP, Doucet J, Lee J, Coimbra R, Bansal V. Gastric trichobezoar causing intermittent small bowel obstruction: Report of a case and review of the literature. Case Reports in Medicine. 2011;2011. 217570. Available from doi: https://doi.org/10.1155/2011/217570
  9. Imran M, Sughra U, Khan A. Huge Gastric and Ileal Trichobezoars Causing Small Bowel Obstruction. J Coll Physicians Surg Pak. 2018;28(1):63-65. Available from: doi: 10.29271/jcpsp.2018.01.63.
  10. Altintoprak F, Gemici E, Yildiz YA, YenerUzunoglu M, Kivilcim T. Intestinal Obstruction due to Bezoar in Elderly Patients: Risk Factors and Treatment Results. Emerg Med Int. 2019;2019:3647356. Available from: doi: 10.1155/2019/3647356. Erratum in: Emerg Med Int. 2019 Sep 2;2019:1568134. PMID: 30911418; PMCID: PMC6398050.
  11. Maglinte DD, Reyes BL, Harmon BH, Kelvin FM, Turner WW Jr, Hage JE, Ng AC, Chua GT, Gage SN. Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol. 1996;167(6):1451-5. Available from: doi: 10.2214/ajr.167.6.8956576.
  12. Frager DH, Baer JW. Role of CT in evaluating patients with small-bowel obstruction. Semin Ultrasound CT MR. 1995 Apr;16(2):127-40. Available from: doi: 10.1016/0887-2171(95)90005-5.
  13. Kramer SJ, Pochapin MB. Gastric phytobezoar dissolution with ingestion of diet coke and cellulase. Gastroenterol Hepatol (N Y). 2012 ;8(11):770-2.
  14. Kumar GS, Amar V, Ramesh B, Abbey RK. Bizarre metal bezoar: a case report. Indian J Surg. 2013;75(Suppl 1):356-8. Available from: doi: 10.1007/s12262-012-0706-2. Epub 2012 Jul 28.
  15. Mohite PN, Gohil AB, Wala HB, Vaza MA. Rapunzel syndrome complicated with gastric perforation diagnosed on operation table. J Gastrointest Surg. 2008;12(12):2240-2. Available from: doi: 10.1007/s11605-007-0460-0. Epub 2008 Jan 3.

Author Contributions

PG: Design, Conception, Writing & Submission
ID & NK: Data Acquisition

Ethical Consideration

Waiver obtained from Institutional Review Board of Shaukat Khanam memorial cancer hospital & research centre on Feb the 28th, 2020. Consent obtained from patient for publication.

Conflict of Interest

The authors did not declare any conflict of interests.

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Manuscript Processing

Submission: PJSM-2020-000178-O-19-Feb-2020
Processing:
PJSM-2020-000178-P-09-Apr-2020
PJSM-2020-000178-P-21-Apr-2020
PJSM-2020-000178-C-26-Apr-2020
PJSM-2020-000178-C-28-Apr-2020
PJSM-2020-000178-E-29-Apr-2020
PJSM-2020-000178-P-01-May-2020
PJSM-2020-000178-E-03-May-2020
Accepted: 03-May-2020
Published: 11-May-2020

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Lead Editor: M.I Anwar
Editor: J. Siddiq, AA Sheikh
Proof: K Zahra
Bibliography: Z Sarfraz

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