[Pharmacobezoar in a woman with a clomipramine intoxication]. / Een bezoar bij een vrouw met clomipramine-intoxicatie.

BACKGROUND: Medicines with controlled release can cause a rare phenomenon, known as pharmacobezoar, following overdose of these medications. CASE DESCRIPTION: A case of a 56-year-old women with severe clomipramine intoxication is described. X-ray of the abdomen showed a cluster of tablets in the caecum. Lab results showed severe plasma concentration of clomipramine. Patient was treated with active coal and remained stable. CONCLUSION: It is important to be aware of the presence of pharmacobezoar in intoxication with controlled release medicines. The formation of pharmacobezoar can lead to unpredictable duration of intoxication.

Gastro-esophageal pharmacobezoar.

A 35-year-old man with schizophrenia died from an overdose of propranolol (blood level = 60 mg/L). Post mortem CT scanning showed marked distension of the esophagus by granular material with a bolus of similar material within the stomach. At autopsy 62 g of lime green pharmacobezoar was present within the esophagus with an additional 130gm mass of similar material within the stomach, both of which contained propranolol. The rest of the gastrointestinal tract was unremarkable. The mouth, pharynx, glottis, larynx, trachea and bronchi were all structurally normal with no obstructive material. Thus, there was no evidence of airway compromise to suggest that the bezoar had mechanically contributed to death. Rather, elution of the drug had resulted in lethal blood levels. The color of the pharmacobezoar derived from the green color of certain propranolol tablets. Death was therefore attributed to propranolol toxicity with an associated finding of a massive gastro-esophageal pharmacobezoar.

Phytobezoar Associated with Levodopa-carbidopa Intestinal Gel Infusion in Patients with Parkinson's Disease: A Case Report and Literature Review.

Continuous intrajejunal infusion of levodopa-carbidopa intestinal gel (LCIG) is an established device-aided therapy for advanced Parkinson's disease (PD). Phytobezoar associated with LCIG is a rare device-related complication and presents with exacerbations of gastrointestinal and PD symptoms. We herein report the case of a phytobezoar that was formed at a knot on the pigtail-shaped J-tube and developed only in association with postprandial abdominal pain, similar to a feeling of a tube being pulled in without an exacerbation of PD symptoms. Such abdominal pain may be a warning sign of phytobezoar in LCIG-treated patients. Despite device-related complications, high-pressure alarms are not always present, and PD symptoms are not always exacerbated.

Endoscopic removal of a gastric pharmacobezoar induced by clomipramine, lorazepam, and domperidone overdose: a case report.

INTRODUCTION: Gastric pharmacobezoars are a rare entity that can induce mechanical gastric outlet obstructions and sometimes prolong toxic pharmacological effects. Certain medications, such as sustained-release forms, contain cellulose derivatives that may contribute to the adhesion between pills and lead to the creation of an aggregate resulting in a pharmacobezoar. Case reports are rare, and official guidelines are needed to help medical teams choose proper treatment options. CASE PRESENTATION: Our patient was a 40-year-old Caucasian woman with borderline personality disorder and active suicidal thoughts who was found unconscious after a massive drug consumption of slow-release clomipramine, lorazepam, and domperidone. On her arrival in the emergency room, endotracheal intubation was preformed to protect her airway, and a chest x-ray revealed multiple coffee grain-sized opaque masses in the stomach. She was treated with activated charcoal followed by two endoscopic gastric decontaminations 12 h apart in order to extract a massive gastric pharmacobezoar by manual removal of the tablets. CONCLUSION: This case demonstrates that in the case of a massive drug consumption, a pharmacobezoar should be suspected, particularly when cellulose-coated pills are ingested. Severe poisoning due to delayed drug release from the gastric aggregate is a potential complication. Detection by x-ray is crucial, and treatment is centered on removal of the aggregate. The technique of decontamination varies among experts, and no formal recommendations exist to date. It seems reasonable that endoscopic evaluation should be performed in order to determine the appropriate technique of decontamination. Care should be patient-oriented and take into account the clinical presentation and any organ failure, and it should not be determined solely by the suspected medication ingested. Thus, serum levels are not sufficient to guide management of tricyclic antidepressant intoxication.

Phytobezoar and duodenal ulcer as complication of Duodopa therapy in a patient affected by Parkinson's disease.

Continuous duodenal infusion of levodopa/carbidopa intestinal gel (LCIG) is an established treatment to control motor fluctuations in Parkinson's disease. Duodenal infusion allows a steady absorption of the drug in the small bowel, reducing plasmatic fluctuations of levodopa. Some complications may occur during the treatment, often related to intrajejunal percutaneous endoscopic gastrostomy (PEG-J). We report a case of duodenal ulcer associated with a phytobezoar involving the end of jejunal probe, in a patient who underwent PEG-J for LCIG infusion. In the last 2 weeks, the patient suffered from abdominal pain and dyspepsia. Oesophagogastroduodenoscopy showed an ulcerative lesion of the duodenum due to traction of the jejunal tube; the end of the jejunal tube was wrapped in a phytobezoar. This case is interesting because of the extension of the ulcerative lesion due to PEG-J dislocation and because of the subtle symptoms associated with it.

A Magnesium Oxide Bezoar.

A 75-year-old Japanese woman presented with nausea and appetite loss. Computed tomography showed a radiopaque substance in the stomach. Esophagogastroduodenoscopy revealed bezoars in the stomach, which were endoscopically retrieved. The bezoars were mainly composed of magnesium and oxide. Although bezoar formation associated with magnesium oxide consumption is infrequently encountered, the present case indicates that pharmacobezoar should be considered among the differential diagnoses in patients who demonstrate a radiopaque mass in the digestive tract and have a history of magnesium oxide use.

Intra-esophageal whitish mass - a challenging diagnosis.

BACKGROUND: Whitish intraluminal esophageal masses might represent the endoscopic feature of a bezoar or a pedunculated tumor, most likely a fibrovascular polyp, without exclusion of other mesenchymal tumors (leiomyoma, lipoma, gastrointestinal stromal tumor, leiomyosarcoma, granular cell tumor). If a process of dystrophic calcification is also encountered the differential diagnosis can be a challenge even after histological analysis, as it is highlighted by our case. CASE PRESENTATION: A 65-year-old female whom took lactate calcium tablets for 5 years presented with progressive dysphagia. A whitish esophageal mass with an appearance of a pharmacobezoar was detected at esophagoscopy. A pedunculated tumor was considered in the differential diagnosis, but the imagistic studies ruled out a pedicle. This intraluminal esophageal mass highly suggestive for a pharmacobezoar was endoscopically removed. The challenge of correct diagnosis was raised by histological examination performed after immersion into trichloracetic acid for decalcification. The identification of hyaline fibrous tissue, with numerous crystalline basophils deposits of minerals, rare fibrocytes and very few vessels brought in discussion a mesenchymal originating mass, most likely a fibrovascular polyp, even the pedicle was not detected. CONCLUSION: Based on our challenging and difficult to diagnose case we proposed an uncommon evolution: auto-amputation and calcification of an esophageal mesenchymal originating tumor (most likely a fibrovascular polyp).

Endoscopic removal of pharmacobezoar in case of intentional potassium overdose.

BACKGROUND: Hyperkalemia is a potentially life-threatening electrolyte abnormality commonly seen in the emergency department (ED). Intentional overdose of potassium supplements is an uncommon occurrence. OBJECTIVE: This case illustrates a novel approach to treatment of pharmacobezoar with esophagogastroduodenoscopy (EGD) and demonstrates its effectiveness in the setting of extended-release potassium chloride overdose. CASE REPORT: A 44-year-old female presented to the ED with intentional ingestion of an unknown amount of extended-release potassium chloride (K-Dur®) tablets and alprazolam (Xanax®). The patient's serum potassium was initially 7.3 mmol/L and she was treated with standard treatments, including albuterol, calcium gluconate, insulin, dextrose, and sodium bicarbonate. Radiographic investigation showed a pharmacobezoar in the gastric fundus. Treatment was then augmented with whole bowel irrigation (WBI) using polyethylene glycol solution via nasogastric tube. Patient did not tolerate the nasogastric tube, became combative with increasing alteration in her level of consciousness, and WBI therapy was stopped. After discussion with the gastroenterologist, the patient was treated with EGD to remove the pharmacobezoar. The EGD was successful in the removal of the pharmacobezoar and the patient's potassium normalized without complications. CONCLUSIONS: We recommend that in cases of suspected or confirmed potassium drug bezoar in the stomach, physicians consider EGD for removal. This allows for normalization of potassium level while preventing adverse sequelae.

Suicidal overdose with relapsing clomipramine concentrations due to a large gastric pharmacobezoar.

The paper presents a case of fatal intoxication after massive sustained-release clomipramine overdosage with prolonged toxicity related to a large gastric pharmacobezoar. 42-year-old female was admitted to the toxicology unit 14 h after drugs ingestion. At admission patient was deeply unconscious, required controlled mechanical ventilation. Serum total level of TCAs was 1955 ng/mL. Gastric lavage revealed no pills. Within the next 12h the patient's clinical condition improved. TCAs level decreased to 999 ng/mL. However, after another 10h the clinical condition started deteriorating again and the patient went into a deep coma requiring controlled mechanical ventilation. TCAs level increased to 2011 ng/mL. X-ray and computed tomography revealed large pharmacobezoar consisted from radio-opaque pills. In the 28th h of hospitalization gastrotomy was performed, confirming presence of pharmacobezoar formed from Anafranil SR tablets. After surgery TCAs level was gradually decreasing. However, the patient's condition did not improve, she died 32 h after gastrotomy. Post-mortem analyses revealed drug and its metabolite toxic levels in blood (clomipramine - 1729 ng/mL, norclomipramine - 431 ng/mL) and toxic levels in internal organs: myocardium (clomipramine - 14,420 ng/g, norclomipramine - 35,930 ng/g), vitreous humor (clomipramine - 1000 ng/mL, norclomipramine - 3110 ng/mL). Described case report indicates that sustained release clomipramine tablets may form pharmacobezoar. X-ray and computed tomography examinations should be considered in cases of massive abuse of sustained release clomipramine, particularly if symptoms of intoxication are recurrent or persistent.

[Medicamentous bezoar following pancreaticoduodenectomy: the combined use of cholestyramine and antisecretory medications as a risk factor in pancreatic surgery]. / Pharmaco-bézoar après duodénopancréatectomie céphalique, association Choléstyramine + antisécrétoires: situation à risque en chirurgie pancréatique?

The authors describe a case of pharmaco-bezoar consisting of ingested cholestyramine which occurred post pancreaticoduodenectomy. Intestinal obstruction by a cholestyramine bezoar is a rare occurrence but is worthy of note in the post-pancreatectomy setting where there is often concomitant use of cholestyramine, proton pump inhibitors, and octreotide.

Endoscopic removal of slow release clomipramine bezoars in two cases of acute poisoning.

INTRODUCTION: Acute gastroscopy is seldom advocated in cases of drug overdose. However, this intervention is sometimes recommended in cases where a pharmacobezoar of toxic tablets has formed. CASE REPORTS: We describe two patients who were admitted after major ingestion of slow release clomipramine. In one case an abdominal x-ray was highly suspicious of a large pharmacobezoar in the stomach and in the other case a tablet conglomerate totally obstructed the oesophagus. Both conditions were successfully managed by acute gastroscopy. DISCUSSION: There are limited and inconclusive recommendations in the literature concerning the optimal treatment of pharmacobezoars. CONCLUSION: This article provides further evidence that slow release clomipramine may be capable of forming a radio-opaque pharmacobezoar. The clinical courses in these two cases suggest that tablet removal by gastroscopy should be considered in selected cases of drug poisoning. Suspicion of a pharmacobezoar may warrant diagnostic investigations such as imaging studies and endoscopy.