Small intestinal obstruction caused by the gastric bezoars in elderly diabetic patients: A case report

Abstract

Introduction

Bezoar is an unusual cause of small bowel obstruction accounting for 0.4–4 % of all mechanical bowel obstruction. With the rising incidence of diabetes and the associated risk of gastrointestinal issues.

Case presentation

A 59-year-old female diabetic patient with no prior surgical history presented with severe nausea, vomiting, and abdominal pain. CT scan revealed dilated small bowel loops, and endoscopy showed gastric retention with an impacted fecalith in the descending duodenum. At exploratory laparotomy, a bezoar was found impacted in jejunum 5–6 in. away from the Treitz ligament and was removed through an enterotomy.

Clinical discussion

The discussion highlights the rarity of bezoar-induced small bowel obstruction and the diagnostic challenges it presents. Despite its low incidence, it is essential to consider phytobezoars in the differential diagnosis of small bowel obstruction, especially in middle-aged to older adult diabetic patients. The case underscores the importance of a detailed patient history and the use of imaging modalities such as computed tomography (CT) for accurate diagnosis. Early intervention is critical to prevent serious complications like bowel ischemia or perforation. When conservative treatments are ineffective, surgical intervention becomes necessary.

Conclusion

Bezoar-induced small bowel obstruction remains an uncommon diagnosis. A detailed patient history and appropriate imaging are vital for timely diagnosis. It should be suspected in patients with an increased risk of bezoar formation, such as in middle-aged to older adult diabetic patients or a history suggestive of increased fiber intake. CT scan is helpful for preoperative diagnosis. and highlights the need for increased awareness among clinicians regarding the management of bezoars.

1. Introduction

An intragastric bezoar is a firmly packed collection of partly digested or undigested food content that is incapable of exiting the stomach [1]. It is found in the duodenum [2]. Small intestinal obstruction secondary to gastric bezoars is a rare complication. Secondary small intestinal obstruction usually occurs in adults with intestinal diseases such as tumors, polyps, tubercles, adhesions and Meckel's diverticulum [2]. Early diagnosis and treatment can reduce complications and reduce the risk of surgical intervention, especially for elderly patients [3,4]. Herein, we report retrospectively a case report of a patient was cured and discharged in our hospital with a giant gastric bezoar. This case was reported in line with the SCARE criteria [5].

2. Case report

A 59-year-old woman with type 2 diabetes and hypertension was admitted on October 19, 2023, for nausea, vomiting, bloating, and upper abdominal pain after eating, worsening over five days. On physical examination, distension and tenderness were observed in the upper abdomen without any rebound tenderness. The patient did not suffer any gastrostomies or trauma. A CT scan of the chest, abdomen, and pelvis with contrast enhancement revealed multiple air/fluid levels and dilated stomach/duodenum (Fig. 1).

Fig. 1.

The CT with contrast: multiple air/fluid levels and dilated stomach/duodenum (yellow circles, blue and green arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

The first gastroscopy examination was completed on October 19, 2023 (Fig. 2), which revealed gastric retention, ulcers, and stone that initially found at the junction of the duodenal bulb and the descending part. The method of using sodium bicarbonate in combination with Coca-Cola to dissolve stones has not yet led to an improvement in symptoms, thus follow-up gastroscopy was performed on October 23, 2023, and October 31, 2023 (Fig. 3, Fig. 4, Fig. 5), respectively. The stone was observed to have moved to the descending part of the duodenum, and partial fragmentation and removal of the stone were successfully carried out via forceps. Her condition improved. Five days later. She started to experience aforementioned symptoms, accompanied by constipation. On November 9, 2023 (Fig. 6), the patient underwent a fourth endoscopic lithotripsy. A large amount of retained fluid was observed in the gastric cavity, and the mucous lake presented a yellow-green colour. In the descending segment of the duodenum, multiple ulcers ranging from 0.3 to 0.8 cm in diameter were visible, with irregular edges, covered with yellow-white necrotic tissue, without signs of bleeding. A 3.0 cm black-green bezoar was found obstructing the descending part of the duodenum. Attempts were made to capture and fragment the bezoar via electrosurgical snares, but the bezoar was poorly mobile and extremely hard, with only a small portion being successfully broken apart. Considering the difficulty of endoscopic lithotripsy, the patient was referred for surgical treatment on November 10, 2023. Preoperative checks were conducted to confirm that there were no contraindications for surgery. Under general anesthesia, an exploratory laparoscopy and enterotomy were performed, and the bezoar was successfully removed, which approximately 5 cm in diameter, was palpated in the jejunum, 5–6 in. away from the Treitz ligament, fixed and immovable. The gastric bezoar presented a hard, dark brown outer shell, composed predominantly of vegetable fibers, fecal matter, and other undigested materials. No hair or other insoluble substances were detected within the specimen. There are no polyps, masses, or annular stenosis were observed in the small intestine. The patient was discharged November 25, 2023, with a medical therapy and prokinetics proton pump inhibitors, in good condition, with no recurrence noted at 9-month follow-up.

Fig. 2.

Upper GI endoscopy: gastric retention, ulcers, and duodenal stone.

Fig. 3.

A giant 3-cm-diameter gastric diospyrobezoar.

Fig. 4.

Upper gastro-intestinal endoscopy showing a necrotic pressure ulcer.

Fig. 5.

Fragmented partly phytobezoar: polypectomy snare was used to fragmentize the bezoar.

Fig. 6.

Endoscopy: ulcer, 3 cm Bezoar, Yellow-Green Mucosa Lake. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

3. Discussion

Gastric bezoars can be categorized on the basis of the type of food ingested into phytobezoars (plant-derived), zoobezoars (animal-derived), pharmacobezoars (drug-derived), and mixed bezoars [1,6,7]. In China, phytobezoars are the most common, often resulting from the consumption of large amounts of fruits such as persimmons, hawthorns, and black dates on an empty stomach [2,6]. Regrettably, in this case, we were unable to obtain critical dietary history information that could have led to the formation of massive gastric bezoars. Additionally, a history of gastric surgery, delayed gastric emptying (as in the case of diabetes mellitus), diseases and carcinoma of the gastrointestinal tract often lead to undigested food entering the small intestine [8]. Notably, in this case, the patient had a long history of diabetes mellitus which may be a significant contributing factor to the formation of gastric stones. Related literature indicates that diabetic patients with autonomic neuropathy have impaired gastrointestinal emptying functions, increasing the retention time of food in the gastrointestinal tract and thus making bezoar formation highly likely [4]. A patient with diabetes mellitus experienced intestinal obstruction caused by multiple gastric bezoars. Similar to the current case of zoars [6]. In clinical practice, it is crucial to collect dietary histories and consider various potential diseases and risk factors that are likely to contribute to the formation of bezoars.

Small bowel obstruction is a relatively common acute abdominal condition with a variety of complex causes [9]. The bezoar is a rare cause of intestinal obstruction, accounting for 0.4–4 % of all cases of bowel obstruction [6]. Fatih Altintoprak et al. retrospectively analyzed 39 bezoar-induced intestinal obstruction cases; 16 had multiple bezoars: 6 in stomach and jejunum; 5 in stomach and ileum; 2 in jejunum and ileum; 1 with 2 in jejunum, 1 in stomach; 2 with 2 in jejunum [10]. In our study, the patient experienced multiple occurrences of progressively worsening stone impaction at different sites in a short period.

Patients with gastric bezoars are prone to complications such as ulcers, bleeding, and obstruction [6]. However, there are no exact incidence data available. In our case, the occurrence of ulcers was highly prevalent, revealed multiple complex ulcers in the gastrointestinal tract (Fig. 7).

Fig. 7.

Multiple complex ulcers in the esophagus, stomach, and duodenum.

The diagnostic accuracy of bezoar-induced intestinal obstruction by abdominal CT is most likely the best imaging modality [11]. The typical CT features of bezoars are round or oval-shaped densities within the intestinal lumen with inhomogeneous internal appearances, featuring sieve-like reduced-density areas and bubble-like low-density shadows [8]. Contrast-enhanced CT scans can also assess the course of intestinal vessels and detect any ischemic changes in the local bowel segments [3,8]. In this case, the patient underwent a second abdominal CT scan (November 8, 2023 (Fig. 8)), and the comparative results revealed new dilation of the ascending part of the duodenum. Endoscopy is also helpful for diagnosis [12]. The endoscopic and imaging examination results of this case were able to establish a diagnosis.

Fig. 8.

The cross section of abdominal CT scan shows the dilated the proximal duodenum (yellow circle). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Therapies for gastric bezoars currently include chemical dissolution, endoscopic intervention, and surgical treatment [1]. This first type of treatment requires at least 12 h to 2 months [13]. In this case, Despite the patient's intake of sodium bicarbonate solution for 5 days, three lithotripsy procedures failed to remove the stone. We believe that this may be related to the mobility of the bezoars within the digestive tract, preventing adequate penetration by the sodium bicarbonate solution. Additionally, the prolonged formation time of the bezoar may have furt her led to the formation of a hard outer shell, further hindered solution penetration. However, this hypothesis needs to be proven by future studies. Endoscopic treatment of gastric bezoars involves the use of foreign body forceps, snares, lithotripsy baskets, etc. [14] Recent similar case reports have shown that endoscopic treatment can lead to symptom improvement and disease alleviation, achieving effective results [15]. Large gastric bezoars frequently require time-consuming or multiple sessions to achieve complete fragmentation of the foreign body [6,16]. The relevant literature has reported cases of combined chemical drug therapy and endoscopic treatment for gastric bezoars. In the case reported by Samiullah Khan et al., a 49-year-old male patient was treated with Coca-Cola combined with endoscopic lithotripsy via biopsy forceps and snares [1]. On the other hand, phytobezoars causing small bowel obstruction ara relatively uncommon, and the main management method is usually surgery [17]. A clinical study revealed that gastric bezoar can induce perforation, hemorrhage, and shock, while phytobezoar can cause pyloric obstruction and gastric necrosis, both conditions requiring surgery [15]. In the case reported by Giuseppe Di Buono et al., a 68-year-old male patient underwent emergency surgery due to perforation and bleeding caused by a 10 cm gastric phytobezoar [11]. In this case, the patient was a middle-aged to older adult person in poor general condition. Despite attempts at nonsurgical treatment, including medication, endoscopic stone removal and lithotripsy, the patient's symptoms did not improve significantly after several days. Continuing conservative treatment could lead to further loss of intestinal fluids, exacerbate electrolyte imbalances, or even trigger intestinal stenosis and necrosis. Failing to clearly grasp the surgical indications during conservative treatment and delaying the surgical timing can increase the surgical risk and postoperative mortality rate [3]. Owing to the fact that the patient's symptoms did not improve after multiple endoscopic lithotripsy treatments in a short period, we considered whether there might be other impacted stones in the intestines. Therefore, surgical treatment not only rapidly alleviates patients' obstructive symptoms but also prevents further deterioration and restores the patency of the digestive tract. It is crucial to thoroughly examine the entire digestive tract during surgery to prevent the recurrence of intestinal obstruction due to overlooked bezoars, which could increase the risk of secondary surgery [18].

4. Summary

In summary, gastric bezoar-induced small bowel obstruction is a relatively rare clinical emergency. The variability and atypical nature of symptoms, which can change as the bezoar moves, make it challenging for clinicians to promptly recognize and consider this condition. However, by conducting a systematic and comprehensive medical history, physical examination, and necessary auxiliary tests for the susceptible population, it is still possible to make an early and timely diagnosis. The non-suigical treatment methods not only alleviate the patient's suffering but also improve the patient prognosis. Therefore, it is essential to advocate for and value early and accurate etiological diagnosis. Nevertheless, when medical treatment is ineffective or there are indications for emergency surgery, active surgical intervention should also be considered.

CRediT authorship contribution statement

Y.F.: conceptualization, investigation, writing – original draft, and writing review and editing. S.: writing – review and editing. J.: conceptualization, supervision, and project administration.

Consent to participate

Not applicable.

Ethical approval

None required. Because the study was granted exemption by the ethics committee of The Affiliated Hospital of Hebei University.

Guarantor

Yifan Huang accepted full responsibility for the work.

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2. Unique identifying number or registration ID: Not applicable.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable.

Consent for publication

Informed consent was obtained and signed from the patients and personal information in these studies was kept confidential.

Sources of funding

None applicable.

Statement

The present study is an original research that has not been published previously, all authors agree to submit to this journal. and not under consideration for publication elsewhere, in whole or in part.

Declaration of competing interest

The authors have no potential conflicts of interest to disclose.

Data availability

Not applicable.