Pharmacobezoar Associated Prolonged Clinical Course in a Patient with Immediate Release Quetiapine Overdose.

INTRODUCTION: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is not certain whether quetiapine IR overdose would similarly cause a delayed increase in serum quetiapine concentrations. CASE REPORT: A 57-year-old woman with depression who was taking half a tablet of 25 mg quetiapine IR daily was transported to our emergency department with a complaint of disturbance of consciousness 12 h after a quetiapine IR overdose. On arrival, her initial vital signs were heart rate of 116 beats per minute, blood pressure of 77/43 mm Hg, and oxygen saturation of 91% under 10 L oxygen administration. Whole body plain computed tomography showed a large amount of gastric hyperdense content suggesting pharmacobezoar with a volume of 71.2 ml. After treatment with respiratory and circulatory support, gastric lavage was performed. Her disturbance of consciousness persisted until day 5, and she was extubated on day 7. The serum concentrations of quetiapine were 2690 ng/mL at 12 h after overdose, 5940 ng/mL at 40 h, and 350 ng/mL at 124 h after overdose. Serum concentrations of other co-ingestions were all below lethal levels. CONCLUSION: A massive quetiapine IR overdose with pharmacobezoars can cause a delayed increase in serum quetiapine concentrations.

Failure of Computed Tomography (CT) in Detecting an Aspirin Pharmacobezoar: A Case Report.

BACKGROUND Prior studies suggest CT can identify bezoars under certain circumstances. Endoscopy provides diagnostic and therapeutic benefit in the setting of suspected aspirin bezoar. Does the absence of findings on CT scan exclude the presence of an aspirin bezoar? CASE REPORT A 64-year-old woman called the police and stated she ingested a bottle of aspirin to harm herself. Upon arrival to the Emergency Department, she was tachypneic with a GCS of 15. Initial laboratory results were: salicylate level of 1143 mcg/mL, respiratory alkalosis, bicarbonate of 9 meq/L, anion gap of 23, and normal renal function. Initial therapeutic intervention included infusions of glucose and bicarbonate, multiple doses of activated charcoal, intubation, and emergent hemodialysis. After hemodialysis, the salicylate level rebounded, and a Gastroenterology (GI) consultation was requested to rule out bezoar. On day 2, GI requested an abdominal CT scan with Gastrografin in place of endoscopy due to hemodynamic instability. A CT scan was negative for bezoar. After multiple hemodialysis sessions and whole-bowel irrigation with rebounding salicylate levels, GI was consulted again for reevaluation for endoscopy. On day 5, an endoscopy discovered a concretion containing pill fragments. Another endoscopy performed on day 7 removed further fragments. Salicylate levels began to consistently decline. Unfortunately, the patient's neurologic status did not improve, and on day 11 she was switched to palliative care and died. CONCLUSIONS Endoscopy with direct visualization is diagnostic and therapeutic in the setting of a possible bezoar. The absence of pharmacobezoar on imaging should not delay endoscopy in a clinical setting suggesting bezoar.

Fitobezoar disuelto químicamente con coca-cola / Chemically dissolved phytobezoar with coca-cola

Los bezoares han estado presentes en la historia de la medicina desde sus inicios, si bien su incidencia es baja y suelen detectarse de manera incidental, es importante tener opciones menos invasivas para su tratamiento debido a que la endoscopia digestiva alta (EDA) no está siempre disponible en todos los centros y, además, muchas veces no logra ser resolutiva debido al tamaño y/o composición del bezoar. En este reporte se presenta el caso de una paciente que, en el contexto de un posible síndrome de CREST, presentó un fitobezoar que fue disuelto con Coca-Cola®, un elemento ampliamente disponible alrededor del mundo, por lo que podría incluso llegar a considerarse como primera línea dentro del manejo no invasivo.

Bezoars have been present in the history of medicine since its inception, although their incidence is low and they are usually detected incidentally, it is important to have less invasive options for their treatment because upper digestive endoscopy (EDA) is not always available in all centers and, moreover, often fails to resolve due to the size and/or composition of the bezoar. This report presents the case of a patient who, in the context of a possible CREST syndrome, presented a phytobezoar that was dissolved with Coca-Cola®, an element widely available around the world, for which reason it could even be considered as the first line of non-invasive management.

Bezoar gástrico, una aproximación al manejo / Gastric bezoar, an approach to medical management

The presence of bezoars in daily clinical practice is a event that poses a challenge both diagnostic, due to the associated factors in its development, as well as therapeutic. The management of this entity is associated with medical, endoscopic and surgical procedures and it is necessary to know its usefulness in different clinical scenarios. The role of carbonated beverages is increasingly accepted given its low cost, wide availability and high efficiency. For the aforementioned, it seems important to report a series of cases and the management performed.

La presencia de bezoares en la práctica clínica diaria es un evento que establece un desafío diagnóstico, por los factores asociados en su desarrollo, como también terapéutico. El manejo de esta patología se asocia a procedimientos médicos, endoscópicos y quirúrgicos siendo necesario conocer su utilidad en distintos escenarios clínicos. El rol de las bebidas carbonatadas es cada vez más aceptado dado su bajo costo, amplia disponibilidad y alta eficacia. Por lo antes señalado, nos parece importante reportar una serie de casos y el manejo realizado.

Clinical and Forensic Aspects of Pharmacobezoars.

BACKGROUND: Pharmacobezoars are specific types of bezoars formed when medicines, such as tablets, suspensions, and/or drug delivery systems, aggregate and may cause death by occluding airways with tenacious material or by eluting drugs resulting in toxic or lethal blood concentrations. OBJECTIVE: This work aims to fully review the state-of-the-art regarding pathophysiology, diagnosis, treatment, and other relevant clinical and forensic features of pharmacobezoars. RESULTS: Patients of a wide range of ages and of both sexes present with signs and symptoms of intoxications or more commonly gastrointestinal obstructions. The exact mechanisms of pharmacobezoar formation are unknown but are likely multifactorial. The diagnosis and treatment depend on the gastrointestinal segment affected and should be personalized to the medication and the underlying factor. A good and complete history, physical examination, image tests, upper endoscopy, and surgery through laparotomy of the lower tract are useful for diagnosis and treatment. CONCLUSION: Pharmacobezoars are rarely seen in clinical and forensic practice. They are related to controlled or immediate-release formulations, liquid, or non-digestible substances, in normal or altered digestive motility/anatomy tract, and in overdoses or therapeutic doses, and should be suspected in the presence of risk factors or patients taking drugs which may form pharmacobezoars.

Gastric phytobezoars: the therapeutic experience of 63 patients in Northern China.

INTRODUCTION: Sixty-three patients with gastric phytobezoars were reviewed. METHODS: forty-eight (76.2%) patients received endoscopic combined with chemical therapies and 15 (23.8%) received only chemical therapy initially. Fifty-one (81.0%) patients achieved complete removal (only chemical therapy 14/15), while 12 (19.0%) received further endoscopic therapies. RESULTS: finally, 62 (98.4%) patients achieved a complete removal. Considering only patients with combined treatment as a first approach, treatment success was associated with a softer phytobezoar consistency (p = 0.023). CONCLUSION: in conclusion, most patients achieve a favorable outcome. Chemical therapy is useful in selected cases. Repeated endoscopic therapies may be needed in order to completely remove phytobezoars with a hard consistency.

An Unusual Mimic of Intermittent Bowel Obstruction.

BACKGROUND Indigestible foreign material in the bowel can develop into bezoars. Intestinal obstruction can occur secondary to these bezoars. Phytobezoars specifically refer to those which accumulate as a result of undigested plant or other food material. CASE REPORT A 42-year-old woman presented to the Emergency Department with a several-month history of right-sided abdominal pain associated with bouts of vomiting. She had no other significant medical history. Labs and computed tomography were unrevealing. Gastroenterology was consulted and performed endoscopy. A foreign body resembling an undigested mini bell pepper was found near the terminal ileum. This was removed, and the patient later reported significant improvement in her symptoms. CONCLUSIONS Phytobezoars can lead to symptoms consistent with intestinal obstruction. The underlying pathology (e.g., masses, gastritis, adhesions, or dysmotility) can precipitate obstructions in the setting of bezoar formation. Surgical removal if often necessary for small-bowel obstructions secondary to bezoars, but in our case, fortunately, the foreign body was successfully removed during endoscopy.

Case of nasogastric tube dysfunction.

CLINICAL PRESENTATION: An elderly female patient was admitted to intensive care for prolonged vasopressor therapy and mechanical ventilation after cardiac arrest and acute percutaneous coronary intervention. Antiplatelet, thyroid hormone replacement and statin therapies were administered through a 14-French nasogastric tube (Nestlé Health Science) and enteral feeding was initiated. Correct position of the nasogastric tube was confirmed radiologically. On the seventh day in the intensive care, our patient was seen to regurgitate soft crumbs into her mouth. The blocked nasogastric tube was removed, but attempts to reinsert another tube failed.Upper GI endoscopy revealed an obstruction of the oesophagus with a milky-yellowish caseous substance 20 cm from the incisors (figure 1). The proximal part of the mass showed a central hole and ring-shaped layers resembling the cut face of a tree trunk.gutjnl;68/2/206/F1F1F1Figure 1Obstruction of the oesophagus with a milky-yellowish caseous substance. QUESTIONS: What caused the obstruction?How should we manage such a problem?

Etiological aspects of intragastric bezoars and its associations to the gastric function implications: A case report and a literature review.

RATIONALE: Intragastric bezoar is a stony mass found trapped in the stomach, though it can occur in other locations of the gastro-intestinal tract. The etiology of intragastric bezoar is multifactorial, includes certain risk factors and predisposing factors such as coexisting medical disorders, anatomic abnormalities, and gastric motility disorders, which contribute to the development of intragastric bezoar. PATIENT CONCERNS: In this report, we present a rare case of intragastric bezoar with epigastric pain after prolonged consumption of jujubes. To our knowledge, this is the first case of intragastric bezoar to be reported after jujubes ingestion. DIAGNOSES: An upper gastrointestinal (GI) endoscopy performed which revealed an 8 × 5-cm intragastric diospyrobezoar with an adjacent necrotic pressure ulcer of size 0.8 × 0.5-cm without signs of bleeding. INTERVENTIONS: For therapeutic intervention, Coca-Cola ingestion and lithotripsy were applied. OUTCOMES: The therapeutic course was uneventful. There was no recurrence during 1-year follow-up. LESSONS: In our literature, jujube emerged as a new player. A bezoar composed of unripened fruit content in the stomach, could be the cause of chronic abdominal pain, dyspepsia, gastric reflux or heartburn. Moreover, this study provides a detailed overview of recently published literature regarding intragastric manifestations of bezoar, etiological factors, diagnostic and therapeutic approaches.

Síndrome de Rapunzel con doble tricobezoar simultáneo en una adolescente: Reporte de caso / Rapunzel syndrome with double simultaneous trichobezoar in a teenager: Clinical Case Report

Resumen: Introducción: Los tricobezoares son acúmulos intraluminales de cabello ingerido. El síndrome de Rapunzel hace referencia a la presencia de los tricobezoares gástricos que se extienden al intestino delgado, sumados a la tricotilomanía y tricofagia, los cuales ocurren preferentemente en pacientes psiquiátricos en edad pediátrica. Objetivo: Analizar la aparición y manejo de este síndrome, propor cionando de igual manera datos acerca del entorno familiar y psicoemocional para que, por medio del análisis de los mismos, en un futuro se pueda identificar el riesgo en pacientes con circunstancias similares. Caso clínico: Paciente femenina de 14 años con antecedentes de tricotilomanía y tricofagia de dos años de evolución, que consultó por cuadro de dolor epigástrico asociado a sensación de plenitud posprandial, náuseas y pérdida de peso. Al examen destacaban áreas alopécicas en el cuero cabelludo y a la palpación abdominal se identificó un plastrón cuyo contorno parecía corresponder a los límites gástricos. En los estudios de imágenes se encontró una ocupación gástrica por bezoar. Con la laparotomía más gastrostomía se identificaron dos tricobezoares simultáneos en estómago y duodeno, que fueron resueltos quirúrgicamente y la paciente fue manejada con abordaje psicoemocional. Conclusión: El síndrome de Rapunzel, lejos de ser meramente una entidad quirúrgica, requiere un apoyo psicoemocional para prevenir su recurrencia y limitar su severidad.

Resumen: Introduction: Trichobezoars are an intraluminal accumulation of ingested hair. The Rapunzel syndrome refers to the presence of gastric trichobezoars which extend to the small intestine together with trichotillomania and trichophagia, that occur predominantly in psychiatric patients of pediatric age. Objective: To analyze the clinical course and resolution of this syndrome in a case report. Likewise, we provide information about the family environment and psycho-emotional context of the patients and help the reader identify similar circumstances in their clinical practice. Case report: Female 14-year-old patient with history of trichotillomania and trichophagia of two years of evolution, who consulted for epigastric pain associated with weight loss, nausea, and postprandial fullness. During the physical examination, the patient was found to have bald patches in the scalp along with a palpable mass that seemed to be confined to the gastric limits. Imaging studies revealed gastric occupation due to a bezoar formation. The patient was treated surgically with laparotomy and gastrostomy, and two simultaneous trichobezoars were removed from the patient´s stomach and duodenum, the patient also underwent psycho-emotional professional counseling. Conclusion: Rapunzel´s syndrome, far for being a merely surgical entity, also requires psychoemotional assessment to prevent it recurrence and limit its severity.

Endoscopic shaving of hair in a gastric bypass patient with a large bezoar.

Trichotillomania can be associated with the formation of trichobezoars (hair ball) usually located in the stomach. Trichobezoars may lead to complications including bowel obstruction, and perforation. Patients with a history of diabetes, certain psychiatric disorders, prior gastric surgery and poor mastication ability are at an increased risk of developing bezoars. We are presenting a case of patient who suffered from a large, recurrent trichobezoar, who had a history of gastric bypass surgery as well as trichotillophagia. The endoscopic method used to remove the large bezoar will also be discussed. We have reviewed the cases published, in which patients developed bezoars after undergoing gastric bypass surgery. The purpose of this study is to raise awareness among clinicians that patients with certain psychiatric issues who had prior gastric surgeries, are at eminent risk of bezoar formation. A multidisciplinary approach including cognitive behavioural therapy, dietary education and pharmacotherapy should be taken to prevent complications.

Obstructive Bezoars of the Small Bowel Treated with Coca-Cola Zero through a Long Intestinal Tube and Endoscopic Manipulation.

An 82-year-old Japanese man visited our hospital with abdominal fullness accompanied by lower abdominal pain. He presented with small bowel obstruction due to multiple diospyrobezoars. The bezoars were successfully removed without any surgical intervention by the administration of Coca-Cola Zero through a long intestinal tube and subsequent endoscopic manipulation. Such a combination may be the treatment of choice for small bowel obstruction due to bezoars.

[A 67-year old man with epigastric pain]. / 67-jähriger Patient mit epigastrischen Schmerzen.

A 67-year-old man suffering from epigastric pain showed a phytobezoar in the endoscopy. Therapy with Coca Cola® and enzymes was initiated. The (partial) lysis led to a migration of the bezoar into the ileum, resulting in a small bowel obstruction. After removal of the remaining bezoar via ileotomy a secondary pneumatosis intestinalis occurred. As a rare finding the (phyto-)bezoar should be considered as a differential diagnosis of abdominal pain - especially considering the rising numbers of bariatric surgery, which is a potential risk factor. Furthermore, intestinal obstruction after migration has to be considered as a relevant complication of treatment.

Adolescent with prolonged toxidrome.

A 13-year-old female was presented to the emergency department following an intentional ingestion. The patient developed significant toxicity including multiple, discreet tonic-clonic seizures. Despite appropriate resuscitation and antidotal management, the patient's symptoms persisted for more than 36 hours post-ingestion. An upright abdominal radiograph was performed revealing a radiopacity suggesting a pharmacobezoar. An esophagogastroduodenoscopy was performed with successful removal of a tennis ball-sized pharmacobezoar. The patient's symptoms subsequently subsided and she recovered fully with no neurologic deficits. Diphenhydramine has not been previously identified as a medication likely to form a pharmacobezoar and has not been shown to be radiopaque. Though bezoar formation is a rare clinical scenario, it is one that toxicologists must consider in patients with clinical courses that persist far beyond expected based on known toxicokinetic principles.

Gastrointestinal phytobezoar following bariatric surgery: Systematic review.

Bezoars are collections of undigested foreign material that accumulate in the gastrointestinal tract. The most common are phytobezoars, which are formed from plant fibers, especially those related to the ingestion of persimmon. Patients who undergo abdominal surgery, including bariatric surgery for obesity, and particularly gastrectomy, are prone to bezoar formation due to reduced gastric motility, loss of pyloric function, and hypoacidity. Bezoars can form months to years postoperatively. Our objective was to review the published literature regarding phytobezoar formation after bariatric surgery. We investigated the entire scientific literature on phytobezoars as a complication after bariatric surgery using PubMed and Embase searches of all reports published to date. We used the following keywords: "phytobezoars" or "bezoars" and "bariatric surgery" or "laparoscopic adjustable gastric band" or "laparoscopic sleeve gastrectomy" or "Roux-en-Y gastric bypass" or "single anastomosis gastric bypass" or "biliopancreatic diversion." Seventeen eligible articles were included in the study. We provide an overview of the incidence, classification, and manifestations of bezoar formation as a rare, late morbidity of bariatric surgery. Treatment options include chemical enzyme therapy, endoscopic dissolution and removal, or surgery. Nutritional counseling regarding bezoar formation and prevention of recurrence after bariatric surgery should emphasize changing eating habits, including sufficient drinking and chewing and avoiding the overindulgence of foods with high-fiber content, especially citrus pith and persimmons. Clinicians should be aware of this potential rare complication. Additional studies are needed to examine the eating habits and food choices of bariatric patients with bezoar complications and to elucidate more clearly the risk factors for this pathologic condition.