Case report

Duodenal Bezoar Following Pyloric-Exclusion Gastrojejunostomy

*Kukreja K,1 Yu P,1 Maiti A,1 Salahudeen A,1 Goyal D,2 and Rahimi E2

1Department of Internal Medicine, The University of Texas Health Sciences Center at Houston, USA

2Division of Gastroenterology, The University of Texas Health Sciences Center at Houston, USA

*Corresponding author: Keshav Kukreja, Department of Internal Medicine, The University of Texas Health Sciences Center at Houston, USA, Tel: +1-504-931-5922: E-mail: keshav1229@gmail.com

Citation: Kukreja K, Yu P, Maiti A, Salahudeen A, Goyal D, and Rahimi E  (2018) Duodenal Bezoar Following Pyloric-Exclusion Gastrojejunostomy J Clin Gastroenterol Dig Disord 2018: 4-6. doi: https://doi.org/10.29199/CGDD.101012

Received:  04 September, 2018; Accepted: 30 October, 2018; Published: 09 November 2018

Keywords: Bezoar, Endoscopy, Pyloric-exclusion gastrojejunostomy

Introduction

Bezoars are large aggregates of ingested material ranging from hair, fruit fibers, and others [1]. Radiographically, bezoars can mimic gastric neoplasms [2]. Complications from bezoars include small bowel obstruction to life-threatening bowel perforation [3]. Majority of patients with bezoars have some history of abdominal surgery [4,5]. While several cases of bezoars have been reported after gastro-duodenal surgeries, this is the first report of bezoar formation due to pyloric-exclusion gastrojejunostomy.

Case Presentation

A 19-year-old woman with history of abdominal trauma during infancy requiring pyloric-exclusion gastrojejunostomy presented with worsening abdominal pain, nausea, vomiting and weight loss over one month. Abdominal computed tomography (CT) revealed a large ovoid intraluminal mass in the duodenal bulb measuring 5.3 x 5.4 x 7.4 cm, and magnetic resonance imaging (MRI) confirmed a large laminated-appearing mass in the second part of the duodenum (Figure 1a and 1b). Esophagogastroduodenoscopy (EGD) revealed gastroesophageal junction at 37 cm, and unremarkable gastric mucosa. Upon traversing the gastrojejunostomy, the efferent limb was unremarkable up to 40 cm. At 70 cm distance in the afferent limb, the large bezoar containing food material (Figure 1c) was seen extending from the third portion of the duodenum to the proximal jejunum (Figure 1d). We found that her pyloric-exclusion was never reversed; suggesting likely bezoar formation due to chronic reflux from the jejunum into duodenum.

Duodenal Bezoar Following Pyloric-Exclusion Gastrojejunostomy

Figure 1:

1a. Computed tomography of the abdomen (axial view) showing a large ovoid intraluminal mass measuring 5.3 x 5.4 x 7.4 cm.

b. Coronal view of T2-weighted magnetic resonance imaging showing the mass in the second part of the duodenum with laminated appearance with a heterogeneous low signal alteration and central fluid signal.

c. Upper endoscopy revealing a large yellow colored bezoar in the proximal jejunum to second portion of the duodenum. The gastric body showed a gastrojejunal anastomosis and proximally altered pylorus with a minimal opening, confirming prior pylorus exclusion surgery.

d. schematic diagram of the location of patient's bezoar.

The patient required laparoscopic pyloroplasty for removal of the bezoar. At 4-month follow-up, she was gaining weight and asymptomatic.

 

Discussion:

Risk factors for bezoar formation include psychiatric illnesses, hypomotility disorders, diabetes, previous gastro-duodenal surgeries, and dietary habits [1,4,5]. Additionally, most patients report a history of abdominal surgery. On imaging, bezoars are usually round, ovoid, and mottled, however they can also have a laminated appearance [6]. Pyloric-exclusion gastrojejunostomy is performed when duodenal ischemia is suspected such as in abdominal trauma. In cases where the pyloric exclusion is not reversed, patients are at risk of bezoar formation due to reflux of food material back into the duodenum or enterolith formation.

Patient Consent: Obtained prior to writing of this case report

References

1. Abbas TO (2011) An Unusual Cause of Gastrointestinal Obstruction: Bezoar. Oman Med J 26: 127-128.

2. Lin YM, Chiu NC, Li AFY, Liu CA, Chou YH et al. (2017) Unusual gastric tumors and tumor-like lesions: Radiological with pathological correlation and literature review. World J Gastroenterol 23: 2493-2504.

3. Erzurumlu K, Malazgirt Z, Bektas A, Dervisoglu A, Polat C et al. (2005) Gastrointestinal bezoars: A retrospective analysis of 34 cases. World J Gastroenterol 11: 1813-1817.

4. Calabuig R, Navarro S, Carrió I, Artigas V, Monés J et al. (1989) Gastric emptying and bezoars. Am J Surgery 157: 287-290.

5. Ben-Porat T, Dagan SS, Goldenshluger A, Yuval JB, Elazary R. (2016) Gastrointestinal phytobezoar following bariatric surgery: Systematic review. Surg Obes Relat Dis 12: 1747–1754.

6. Haaga JR, Boll D (2017). Gastrointestinal Tract. CT and MRI of the Whole Body. Elsevier. Pp1303.