Yamini Katamreddy, MD1, Saikiran Mandyam, MD2, Sai Sudha Valisekka, MD3, Sunil Kumar Sibyala, MBBS4, Preethi Dasarathan, MBBS4, Olaniyi Fadeyi, MD1 1West Anaheim Medical Center, Anaheim, CA; 2South East Health, Dothan, AL; 3University of Minnesota, Minneapolis, MN; 4Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India
Introduction: Bezoar is a collection of partially digested material in the gastrointestinal tract. Pharmacobezoars are made up of medications due to altered gastrointestinal motility or anatomy. Roux-en-Y gastric bypass (RYGB) can be associated with an increased risk for bezoar formation.
Case Description/Methods: A 78-year-old female with RYGB 40 years ago presented with epigastric pain and vomiting for 1 week. Physical examination is remarkable for epigastric tenderness. CT abdomen without contrast revealed a severely dilated proximal gastric remnant consistent with stenosis at diverting gastrojejunal limb. Esophagogastroduodenoscopy (EGD) showed bezoar in the gastric pouch, and severe stricture in the gastrojejunal anastomosis, which was dilated with the balloon. No improvement in her symptoms post-dilatation. The upper GI series revealed the contrast draining into the small bowel without complete obstruction. Bezoar couldn’t be removed during initial EGD due to hard pill debris; a repeat endoscopy was performed to break down the debris piecemeal due to the non-resolution of symptoms. Bezoar formation was due to multivitamins, which were large and bulky. They were changed to an intramuscular route to avoid recurrence.
Discussion: Bezoars are large aggregates of insoluble material in the stomach but can occur at any level. Trichobezoars, lactobezoars, polybezoars, phytobezoars, and pharmacobezoars are various types of bezoars. Pharmacobezoars are made up of medications due to altered gastrointestinal motility or anatomy[1,2]. Obstruction can occur at the site of surgical repair or stenosis[1]. Despite its success in achieving adequate weight loss and resolution of co-morbidities, RYGB may be associated with complications like drug delivery issues and the proclivity for pharmacobezoars[3,4]. They can cause symptoms of gastric outlet obstruction and of their pharmacologic properties [5]. If left untreated, bezoars can lead to complications like bleeding, obstruction, and intestinal perforations[6,7]. The treatment includes whole bowel irrigation or endoscopic or surgical extraction [8]. Nausea and vomiting are common complaints associated with anastomotic stricture but can be associated with bezoars. Pharmacobezoar should be considered as a differential diagnosis with suspected gastrointestinal tract emptying problems post RYGB. Before prescribing any medication, always rule out gastric outlet obstruction, especially if it does not dissolve in acidic media.
Figure: Fig a,b: Coronal and Sagittal view of CT abdomen without contrast revealing a severely dilated proximal gastric remnant consistent with stenosis at diverting gastrojejunal limb. Fig c: Upper GI series revealed the contrast draining into the small bowel without complete obstruction. Fig d: Upper endoscopy revealing pill bezoar intermixed with hard pill debris. Fig e: Balloon dilation of the stricture at the gastrojejunal anastomosis Fig f: Endoscopic diagram demonstrating stricture and bezoar location
Disclosures:
Yamini Katamreddy indicated no relevant financial relationships.
Saikiran Mandyam indicated no relevant financial relationships.
Sai Sudha Valisekka indicated no relevant financial relationships.
Sunil Kumar Sibyala indicated no relevant financial relationships.
Preethi Dasarathan indicated no relevant financial relationships.
Olaniyi Fadeyi indicated no relevant financial relationships.
Yamini Katamreddy, MD1, Saikiran Mandyam, MD2, Sai Sudha Valisekka, MD3, Sunil Kumar Sibyala, MBBS4, Preethi Dasarathan, MBBS4, Olaniyi Fadeyi, MD1. P4220 - Pharmacobezoar Due to Gastric Stricture Post-Roux-En-Y Bypass Surgery: A Case Report, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
