Recurrent gastric metal bezoar: a rare cause of gastric outlet obstruction

Abstract

A 52-year-old male patient with psychiatric medical history who presented to the emergency department five times during a period of 5 years due to gastric outlet obstruction manifested mainly by abdominal pain, vomiting and haematemesis after intentionally ingesting metals and which necessitate several surgical interventions. Lately, he presented with generalised peritonitis due to gastric perforation from metal bezoars. Chronic abdominal symptoms in patient having a psychiatric disorder can be due to foreign body ingestion. Treatment is often surgical and the whole digestive tract should be explored to avoid retained bezoars.

Background

Bezoars are accumulation of foreign bodies formed of partially digested or non-digested foreign material in the gastrointestinal (GI) tract; most commonly found in the stomach but can be seen elsewhere in the digestive tube.¹

Several types of bezoars are named according to the material from which they are composed.

Bezoar could be food boluses composed of loose aggregate of food items, lactobezoar formed by inspissated milk usually seen in infants, pharmacobezoar formed by medical tablets and masses of drugs, phytobezoars composed of indigestible plant material, diospyrobezoar a type of phytobezoar formed by persimmons, trichobezoar formed by ingestion of hair and the least frequent being metal bezoar,² usually seen in patients having psychiatric disorders. Few cases have been reported in the literature.^{3 4}

We present a case of a psychiatric man who was operated several times due to relapsing massive metal bezoars despite psychiatric treatment.

Case presentation

A 52-year-old male patient with chronic psychosis and under specific psychotic treatment, presented in May 2012 with signs and symptoms of gastric outlet obstruction due to the ingestion of metal bezoar, which was removed endoscopically. Eight months later, he was readmitted and operated because of failing endoscopic total removal of the different metals ingested. These bezoars were nails, knifes, screws, nuts, spoon handles, screwdriver head, washer, pebbles, coins and iron wire (figures 1 and 2).

Figure 1.

Radiograph showing metal bezoar.

Figure 2.

Metal items retrieved from patient’s stomach.

Between 2013 and 2016, he was readmitted and operated two times in another institution for gastric metal bezoars after failed endoscopic removal in each intervention. The patient had laparotomy and metal bezoars were removed via gastrotomy.

Lately in December 2016, he was presented to the emergency department with fever and nausea; on physical examination, his vital signs were within normal limits except a moderate sinus tachycardia 110/min and 38°C. He was pale and dehydrated.

Abdominal examination noted guarding throughout the abdomen, maximally in the epigastrium.

A mobile mass was palpable in the left upper quadrant and epigastrium.

He was admitted with provisional diagnosis of generalised peritonitis due to gastric perforation.

Investigations

Blood tests revealed that the patient was septic with a haemoglobin level of 13 g/dL; peripheral white cell count was 20.1 10^9/L with neutrophils 85%. C-reactive protein was 200 mg/L, urea 15 mmol/L and normal creatinine.

Abdominal CT scan showed a foreign body mass in the gastric region and small bowels associated with pneumoperitoneum and free intra-abdominal fluid (figures 3–5)

Figure 3.

CT scan of abdomen showing pneumoperitoneum (arrow) and free intra-abdominal fluid.

Figure 4.

CT scan of abdomen showing intragastric metal and free intra-abdominal fluid.

Figure 5.

CT scan of abdomen showing prepyloric metal with pneumoperitoneum (arrows) and free intra-abdominal fluid.

Differential diagnosis

Differential diagnosis includes ulcer perforation, left transverse colon tumour.

Treatment

The patient ultimately underwent an open laparotomy, bezoars were removed via gastrotomy and many enterotomies since the radiologic perioperative findings help us to localise all the materials and to check for their total removal to prevent recurrence (figures 6 and 7).

Figure 6.

Radiograph showing metal bezoar.

Figure 7.

Metal items retrieved from patient’s stomach.

Outcome and follow-up

To note that those different medical and surgical consultations were despite the theoretically psychiatric medications and follow-up.

The postoperative course was uneventful and the patient was discharged on postoperative day 15 with a referral to behavioural and mental health providers.

Discussion

Bezoars are uncommon findings in the GI tract; they are composed of a wide variety of material depending on the type of the ingestion. By order of frequency, phytobezoar is the most common, followed by trichobezoar, drug bezoar and lactobezoar. Metal bezoar are the least common and very few cases are described in the literature.⁵ Bezoars are usually intentionally ingested, thus they occur in normal stomachs and are caused by foreign bodies that cannot bypass the pylorus.

After reviewing the literature, metal bezoar was reported seven times. The first report was in 1956 by Salb⁶ and the second by Kaplan et al⁴ in 2005; later several cases were reported.1 2 5 7 8 None of the reported case was recurrent, complicated or massive.

However, other bezoars could occur in ‘abnormal’ stomach, for instance, in cases of decreased gastric motility (eg, diabetes mellitus, previous vagotomy, drugs), previous gastrectomy (Billroth 2, gastric bypass), hypochlorydria, gastric stasis, loss of pyloric function and hypothyroidism.⁷ Clinical manifestations vary widely depending on the location of the bezoar that could be anywhere in, the digestive tract and can go from asymptomatic, non-specific symptoms to more serious intestinal obstruction, GI bleeding, perforation and peritonitis.⁹ Metal bezoar can be seen on plain radiographs unless they are radiolucent but CT scan is usually necessary and help identifying localisation and possible complications due to these foreign bodies.^{1 5 7} Gastroscopy confirms the diagnosis, defines the type of the bezoar and could treat the bezoar by its removal if they were small and technically feasible.¹⁰ Although different treatments have been suggested to treat phyto-tricho-bezoars such as coca-cola, papaine saline and other chemical substances for dissolution,¹¹ endoscopic extraction, surgical treatment is usually necessary for metal bezoars.⁸

Metal bezoars could be a rare cause of abdominal concern. They are generally ingested accidentally in adults, usually in infants, elderly, psychotic patients and prisoners. The patient could be asymptomatic. Surgical exploration and extraction is the treatment of choice and thorough exploration of the whole digestive tract is necessary to avoid retained materials. Psychiatric follow-up is mandatory to prevent recurrence that has been reported to be 14% in the literature.¹²

Learning points.

• Chronic abdominal symptoms in patients having mental disorders can be due to foreign body ingestion.

• Surgical exploration and extraction is the treatment of choice.

• Psychiatric close follow-up is mandatory to prevent recurrence.