Laparoscopic management of rare smoked dry pork bezoar in the stomach

Abstract

Medical literature recognise only 4 types of bezoar – phytobezoar, trichobezoar, lactobezoar and pharmacobezoar. Here, we discuss a new unique type of bezoar composed of undigested dry pork. A 58-year-old male patient from Nagaland, India, presented with intermittent symptoms of gastric outlet obstruction and pain abdomen. On clinical examination, he was found to have an epigastric lump. Upper gastrointestinal endoscopy showed an undigested ball of swallowed meat at the pylorus and later at the fundus on repeat endoscopy just before the surgical intervention. Endoscopic mechanical fragmentation was tried, but owing to the large size and hard sticky consistency of the bezoar, fragmentation was not feasible. Due to persistent pain abdomen and clinical gastric outlet obstruction, a decision for operative intervention was taken. He finally underwent laparoscopic anterior gastrotomy and evacuation of the bezoar. The post-operative course was uneventful, and the patient went home symptom free on the 5^th post-operative day.

INTRODUCTION

Bezoars are concretions of undigested material that accumulate in the gastrointestinal tract, mostly in the stomach or terminal ileum and cause symptoms. Medical literature speaks mostly of only of 4 types of bezoar – phytobezoar, trichobezoar, lactobezoar and pharmacobezoar. Foreign body bezoar, trichophytobezoar and worm bezoars are the other types of bezoars found in literature. Here, we discuss a new and unique type of bezoar composed of undigested smoked dry pork in which the patient presented with intermittent symptoms of gastric outlet obstruction and pain abdomen.

CASE REPORT

The patient was a 58-year-old male hailing from Dimapur, Nagaland, India. The practice of taking half-cooked smoked pork is quite common among the residents from the geographical location. He presented to us with the chief complaints of pain abdomen and vomiting after having food. The symptoms appeared 5 days prior, with an onset of around 1 hour after having smoked dry pork. He had no other comorbidity like diabetes or history suggestive of intestinal dysmotility. There was no history of the patient’s psychiatric illness or his family. There was no history of any surgical intervention.

On clinical examination, he was found to have a mobile epigastric lump of 6 cm × 8 cm in the epigastric region.

He underwent primary treatment at a local hospital with analgesics, proton pump inhibitors and antiemetics. He came to us when the above conservative regimen failed.

He underwent contrast-enhanced computed tomography scan with oral contrast [Figure 1], which showed a bezoar in the stomach and upper gastrointestinal (UGI) endoscopy was done to confirm the diagnosis [Figure 2]. The initial trial to break down the bezoar was done with foreign body forceps, but it failed to do so.

Figure 1.

CECT with oral contrast showing bezoar in the stomach. CECT: Contrast-enhanced computed tomography

Figure 2.

Upper GI endoscopy showing stomach bezoar. GI: Gastrointestinal

Once diagnosis was established, immediate decompression of the stomach with a nasogastric tube was done. Gastric lavage with 500 ml normal saline and 50 ml of 8.4% W/V sodium bicarbonate injection was done 6 hourly and continued for 3 days. Throughout the period, the patient complained of abdominal pain, so it was decided to proceed with operative intervention if a repeat UGI endoscopy showed no signs of dissolution of the bezoar or softening. Accordingly, UGI endoscopy was done which showed the bezoar to be in the fundus this time, but it showed no signs of dissolution. Mechanical fragmentation was tried once again, but it again proved to be too hard. A decision for laparoscopic retrieval of the bezoar via anterior gastrotomy was taken. Pros and cons of the surgery were explained to the patient and informed consent was taken for the proposed surgery.

Laparoscopic anterior gastrotomy of around 4 cm was done. The scope was taken to the fundus and mechanical fragmentation was done with the help of toothed graspers. The whole bezoar was retrieved in a retrieval bag and extracted by enlarging the 10 mm port [Figure 3].

Figure 3.

Laparoscopic view of the bezoar through gastrotomy

The patient recovered uneventfully. The pain abdomen subsided and NG tube was removed at the 3^rd post-operative day and started on plain water. Liquid diet was allowed on the subsequent day. He was discharged on 5^th post-operative day with advice of soft diet for a week.

DISCUSSION

Here, we present the only case in medical literature who presented with a meat bezoar. The meat here is half-cooked smoked pork meat and is eaten so by a specific population of a geographical location. Medical literature mainly recognises four types of bezoar-phytobezoar, trichobezoar, lactobezoar and pharmacobezoar.[1] Foreign body bezoar is another type which is found in literature and this term covers a wide range of foreign bodies but not meat. Management has always been challenging for bezoars, given that a wide variety of agents have been tried for spontaneous resolution of bezoars like papain, sodium bicarbonate, carbonated soda water, cellulase, meat tenderiser, etc., but the results have been inconsistent, sometimes with some adverse events.[2-4] Again, there is a limit to how many days we can continue conservative management with enzymes, given the nutritional compromise associated with keeping the patient nil orally for proper contact of the enzymes with the bezoar. Retrieval of the bezoar via UGI endoscopy was not feasible in this case since it was too hard and sticky to be fragmented by the small foreign body forceps. The only option left was operative management, so laparoscopic gastrotomy and retrieval of the bezoar was done.

CONCLUSION

Half-cooked smoked pork meat can cause bezoar formation in the gastrointestinal tract. Although it is difficult to point out what precipitates this, it can be safely said that it does have the potential to form bezoars. It is difficult to manage via non-operative means. Laparoscopic surgical management seems to be the optimal management modality if endoscopic retrieval fails.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.