Gastric bezoar in anorexia nervosa
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Vol. 12: e28-e29, March 2007 CASE REPORT e28 Key words: Anorexia nervosa, eating disorders, bezoar, gastric, gastrointestinal. Correspondence to: Prof. C. Laird Birmingham Eating Disorders Program St. Paul’s Hospital 1081 Burrard Street Vancouver, British Columbia V6Z 1Y6, Canada E-mail: [email protected] Received: November 6, 2006 Accepted: December 13, 2006 Gastric bezoar in anorexia nervosa C. Laird Birmingham* , **, S. Cardew***, and S. Gritzner* *Eating Disorders Program, University of British Columbia, St. Paul’s Hospital, **Centre for Health Evaluation and Outcome Studies, St. Paul’s Hospital, and ***Department of Medicine, University of British Columbia, Vancouver, B.C., Canada ABSTRACT. OBJECTIVE: To report the case of a gastric bezoar in a patient with anorexia nervosa (AN). METHOD: Case report of a bezoar of the stomach occurring in AN and a review of the literature relating to bezoars and AN from PubMed. RESULTS: A 19 year-old female presented with a 2-year history of AN binge-purge subtype. After 7 days of complete adherence to diet and no purging in hospital, she complained of increased nausea. She vom- ited up a cylindrical mass that was sent for pathology. A literature search yielded only one report of a bezoar in AN. DISCUSSION: Bezoars are agglomerations of food or foreign material in the intestine. They usually present with abdominal pain, intestinal obstruction, weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred method of diagnosis. Clinicians should consider the diagnosis of a bezoar in AN if there is concomi- tant pica, trichotillomania, or a change in gastrointestinal symptomatology. (Eating Weight Disord. 12: e28-e29, 2007). © 2007, Editrice Kurtis CASE REPORT A 19 year-old girl with AN, binge-purge subtype was admitted to the eating disor- ders unit for weight loss and volume deple- tion. She reported intermittent fasting and hematemesis of small amounts of blood. She was adherent to the prescribed diet and denied purging in hospital. Seven days later she felt nauseous and vomited. The emesis contained a small amount of blood as well as a cylindrical bezoar: length 4 cm, cross-section 1 cm by 0.8 cm, weighing about 3 gm. She admitted to chewing gum but said she did not often swallow it. She denied chewing her hair. Gastrointestinal review of systems was significant for purging, the occasional feeling of food getting stuck at the level of her epigastrium, constipation and an episode of overflow diarrhea. Physical examination revealed parotid hypertrophy bilaterally. Complete blood count, creatinine, electrolytes, magnesium, calcium and phosphorus were all within normal range. She had been taking venlafaxine before hospital. In hospital, she was prescribed olanzapine, rabeprazole, domperidone, docusate, potassium chloride, zinc, a multi-vitamin and ciprofloxacin for a uri- nary tract infection (staphylococcus saprophyticus). A CT scan was obtained, but it was of poor quality and could not be interpreted. In order to rule out an anatomical abnor- mality and to ensure that there was no remaining bezoar that might require surgi- cal removal, the patient had an esopha- gogastroduodenoscopy. This was normal except for a small hiatus hernia. The pathology of the bezoar was interest- ing. It showed amorphous debris and bire- fringent foreign material, some resembling vegetable matter. It was contaminated with yeast spores and bacterial colonies. DISCUSSION There is only one citation for bezoar and AN in the literature (1). The types of gas- tric bezoars are listed in Table 1 (2, 3). A trichobezoar is more likely to occur in a patient who has trichotillomania or a localized area of alopecia (4-9). Swallowing incompletely chewed insolu- ble fibre from vegetable sources increases the chance of developing a phytobezoar (10). Lactobezoars occur only in new- borns. Foreign material is more likely to cause a bezoar with comorbid pica (iron deficiency associated with unusual crav- ings) (11-13). The presentation of gastric bezoars is presented in Table 2. New, worsening, or unusual gastrointestinal symptoms should raise the suspicion of a gastrointestinal
Transcript of Gastric bezoar in anorexia nervosa
Vol. 12: e28-e29, March 2007
CASEREPORT
e28
Key words:Anorexia nervosa, eatingdisorders, bezoar, gastric,gastrointestinal.Correspondence to:Prof. C. Laird BirminghamEating Disorders ProgramSt. Paul’s Hospital1081 Burrard StreetVancouver, British ColumbiaV6Z 1Y6, CanadaE-mail:[email protected]
Received: November 6, 2006Accepted: December 13, 2006
Gastric bezoar in anorexia nervosa
C. Laird Birmingham*,**, S. Cardew***, and S. Gritzner**Eating Disorders Program, University of British Columbia, St. Paul’s Hospital, **Centre for Health Evaluationand Outcome Studies, St. Paul’s Hospital, and ***Department of Medicine, University of British Columbia,Vancouver, B.C., Canada
ABSTRACT. OBJECTIVE: To report the case of a gastric bezoar in a patient with anorexianervosa (AN). METHOD: Case report of a bezoar of the stomach occurring in AN and areview of the literature relating to bezoars and AN from PubMed. RESULTS: A 19 year-oldfemale presented with a 2-year history of AN binge-purge subtype. After 7 days of completeadherence to diet and no purging in hospital, she complained of increased nausea. She vom-ited up a cylindrical mass that was sent for pathology. A literature search yielded only onereport of a bezoar in AN. DISCUSSION: Bezoars are agglomerations of food or foreignmaterial in the intestine. They usually present with abdominal pain, intestinal obstruction,weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred methodof diagnosis. Clinicians should consider the diagnosis of a bezoar in AN if there is concomi-tant pica, trichotillomania, or a change in gastrointestinal symptomatology.(Eating Weight Disord. 12: e28-e29, 2007). ©2007, Editrice Kurtis
CASE REPORT
A 19 year-old girl with AN, binge-purgesubtype was admitted to the eating disor-ders unit for weight loss and volume deple-tion. She reported intermittent fasting andhematemesis of small amounts of blood.She was adherent to the prescribed dietand denied purging in hospital.
Seven days later she felt nauseous andvomited. The emesis contained a smallamount of blood as well as a cylindricalbezoar: length 4 cm, cross-section 1 cm by0.8 cm, weighing about 3 gm.
She admitted to chewing gum but saidshe did not often swallow it. She deniedchewing her hair. Gastrointestinal reviewof systems was significant for purging, theoccasional feeling of food getting stuck atthe level of her epigastrium, constipationand an episode of overflow diarrhea.Physical examination revealed parotidhypertrophy bilaterally. Complete bloodcount, creatinine, electrolytes, magnesium,calcium and phosphorus were all withinnormal range.
She had been taking venlafaxine beforehospital. In hospital, she was prescribedolanzapine, rabeprazole, domperidone,docusate, potassium chloride, zinc, amulti-vitamin and ciprofloxacin for a uri-nary tract infection (staphylococcussaprophyticus).
A CT scan was obtained, but it was of
poor quality and could not be interpreted.In order to rule out an anatomical abnor-mality and to ensure that there was noremaining bezoar that might require surgi-cal removal, the patient had an esopha-gogastroduodenoscopy. This was normalexcept for a small hiatus hernia.
The pathology of the bezoar was interest-ing. It showed amorphous debris and bire-fringent foreign material, some resemblingvegetable matter. It was contaminated withyeast spores and bacterial colonies.
DISCUSSION
There is only one citation for bezoar andAN in the literature (1). The types of gas-tric bezoars are listed in Table 1 (2, 3). Atrichobezoar is more likely to occur in apatient who has trichotillomania or alocalized area of alopecia (4-9).Swallowing incompletely chewed insolu-ble fibre from vegetable sources increasesthe chance of developing a phytobezoar(10). Lactobezoars occur only in new-borns. Foreign material is more likely tocause a bezoar with comorbid pica (irondeficiency associated with unusual crav-ings) (11-13).
The presentation of gastric bezoars ispresented in Table 2. New, worsening, orunusual gastrointestinal symptoms shouldraise the suspicion of a gastrointestinal
©
Eating Weight Disord. 12: e28-e29, 2007©2007, Editrice Kurtis
chotillomania, pica, or habitual swallowing ofindigestible material.
REFERENCES
1. Scobie B.A.: Acute gastric dilatation and duodenalileus in anorexia nervosa. Med. J. Aust., 2, 932-934,1973.
2. Andrus C.H., Ponsky J.L.: Bezoars: classification,pathophysiology, and treatment. Am. J. Gastroenterol.,83, 476-478, 1988.
3. Erzurumlu K., Malazgirt Z., Bektas A., Dervisoglu A.,Polat C., Senyurek G., Yetim I., Ozkan K.:Gastrointestinal bezoars: a retrospective analysis of 34cases. World J. Gastroenterol., 11, 1813-1817, 2005.
4. Larsson L.T., Nivenius K., Wettrell G.: Trichobezoar ina child with concomitant coeliac disease: a case report.Acta Paediatr., 93, 278-280, 2004.
5. O’Sullivan M.J., McGreal G., Walsh J.G., RedmondH.P.: Trichobezoar. J. R. Soc. Med., 94, 68-70, 2001.
6. Sharma N.L., Sharma R.C., Mahajan V.K., SharmaR.C., Chauhan D., Sharma A.K.: Trichotillomania andtrichophagia leading to trichobezoar. J. Dermatol., 27,24-26, 2000.
7. Salaam K., Carr J., Grewal H., Sholevar E., Baron D.:Untreated trichotillomania and trichophagia: surgicalemergency in a teenage girl. Psychosomatics, 46, 362-366, 2005.
8. Kumar A., Jazieh A.R.: Case report of sideroblasticanemia caused by ingestion of coins. Am. J. Hematol.,66, 126-129, 2001.
9. Hassan H.A., Netchvolodoff C., Raufman J.P.: Zinc-induced copper deficiency in a coin swallower. Am. J.Gastroenterol., 95, 2975-2977, 2000.
10. Hayes P.G., Rotstein O.D.: Gastrointestinal phytobe-zoars: presentation and management. Can. J. Surg., 29,419-420, 1986.
11. Adler A.I., Olscamp A.: Toxic ‘sock’ syndrome bezoarformation and pancreatitis associated with iron defi-ciency and pica. West. J. Med., 163, 480-482, 1995.
12. Chiu B., Ciaccio C., West M.A.: Intestinal obstructionfrom furniture cushion foam bezoar. Surgery, 138, 956-958, 2005.
13. Nowicki M.J., Miller R.C.: Secretory diarrhea owing toa tape bezoar in a child with Hirschsprung’s disease. J.Pediatr. Surg., 38, 1670-1672, 2003.
14. Zissin R., Osadchy A., Gutman V., Rathaus V., Shapiro-Feinberg M., Gayer G.: CT findings in patients withsmall bowel obstruction due to phytobezoar. Emerg.Radiol., 10, 197-200, 2004.
15. Wai C.T., Lau G., Sutedja D.S.: Clinics in diagnosticimaging (104): Gastric trichobezoar (or hairball).Singapore Med. J., 46, 359-361; quiz 362, 2005.
16. Alsafwah S., Alzein M.: Small bowel obstruction due totrichobezoar: role of upper endoscopy in diagnosis.Gastrointest. Endosc., 52, 784-786, 2000.
17. Gaya J., Barranco L., Llompart A., Reyes J., ObradorA.: Persimmon bezoars: a successful combined ther-apy. Gastrointest. Endosc., 55, 581-583, 2002.
18. Gupta R., Share M., Pineau B.C.: Dissolution of anesophageal bezoar with pancreatic enzyme extract.Gastrointest. Endosc., 54, 96-99, 2001.
Bezoar in AN
cause unrelated to the eating disorder, such asa bezoar.
The CT scan of the abdomen is the preferredinitial investigation of a bezoar because it issensitive, although not specific (14, 15). Boththe abdominal x-ray and ultrasound are notsensitive for the diagnosis of gastric bezoar. Ifthe CT scan is suggestive, an esophagogastro-duodenoscopy can confirm the diagnosis (16).
A gastric bezoar can sometimes be removedusing cutting or lasar with endoscopy (17).Alternatively, laparotomy may be necessary ifendoscopy is unsuccessful. Rarely, pancreaticenzymes dissolve a gastric bezoar, if it isdigestible (18).
Gastric bezoars are rare and, based on theliterature, are very rare in AN. However, a gas-tric bezoar could go undiagnosed in ANbecause the associated symptoms are similar tothose of the eating disorder (Table 2). Bezoarsare more likely to occur in patients with tri-
e29Eating Weight Disord., Vol. 12: N. 1 - 2007
TABLE 1Types of bezoars.
TrichobezoarHair
PhytobezoarPlant material
LactobezoarConcentrated milk Formulas
MiscellaneousFoodChemicalsMedicationsForeign bodies
TABLE 2Symptoms of gastric bezoars.
Most commonAbdominal painIntestinal obstruction
Less commonWeight lossPoor appetiteVomitingMalnutritionWeight loss
RareUlcer (with or without bleeding)PerforationIntussusceptionCholestatisProtein-losing gastroenteropathyPancreatitis
