SUCCESSFUL TREATMENT OF PRIMARY ESOPHAGEAL PHYTOBEZOAR BY TWO-STAGE FLEXIBLE GASTROINTESTINAL ENDOSCOPY:
A CASE REPORT

Dr Amit Thadhani MS, FMAS
Head, Department of Minimal Access Surgery, Niramaya Hospital
Maitri Park, Sion Trombay Road, Chembur, Mumbai-400071

ABSTRACT
A 64-year old lady presented with progressively increasing dysphagia over six months. Upper gastrointestinal endoscopy showed severe esophagitis with a very soft phytobezoar with a normal stomach. Extraction was attempted but was unsuccessful. The patient was put on a clear liquid diet for two weeks and taken up for re-endoscopy, during which the phytobezoar was successfully removed.
Primary esophageal bezoars are very rare but are known to occur in patients with structural and functional abnormalities of the esophagus. They occur in patients with esophageal motility disorder or anatomical defects.

INTRODUCTION
Bezoars are retained concretions of undigested foreign material that accumulate and coalesce within the gastrointestinal tract, most commonly in the stomach. They are of four basic types: trichobezoar (containing hair), phytobezoar (containing undigested food material), lactobezoar (containing milk residue), pharmacobezoars (containing medications such as psyllium husk, sucralfate etc) or combinations of these. Esophageal bezoars are very rare but are known to occur in patients with structural and functional abnormalities of the esophagus such as esophageal motility disorders or anatomical defects. They may also occur in patients with particular eating habits, such as excessive consumption of persimmon, psyllium husk or chewing gum. Critically ill patients on mechanical ventilator receiving feeds via nasogastric tubes, and receiving sucralfate and antacid therapy are also at risk of development of esophageal bezoars.

CASE REVIEW
A 64-year old blind lady was brought to the Department of Minimal Access Surgery for symptoms of progressively increasing dysphagia since at least six months progressing to dysphagia for liquids as well as solids. She was a vegetarian and had a habit of eating food in lying-down position. Upper gastrointestinal endoscopy showed that the upper, mid and lower esophagus were inflamed with extensive ulcerations (grade III esophagitis). There was extensive food residue upto 32 cms and a non-mobile bezoar at 28cms to 32cms. Food residue was lavaged and cleared. The cardia was at 35cms, was lax and showed hiatus hernia. The stomach and duodenum were normal. Presence of food residue in the esophagus, reflux and severe ulcerations made the attempted extraction itself hazardous. The bezoar was extremely soft and not amenable to primary extraction and hence the extraction had to be deferred after attempts at extraction and fragmentation failed. The patient was put on a clear liquid diet consisting water, coconut water and finely strained soups to maintain nutritional well being of the patient to ensure lavage of the esophagus and to provide an interval for healing of extensive ulcerations before reassessment after two weeks. On re-endoscopy, the upper, mid and lower esophagus were relatively less ulcerated and showed grade II esophagitis with significant healing as compared to earlier study. The non-mobile bezoar at 28cms to 32cms seen on earlier study was still in situ and only a central core of hardened fibrous material was left, consistent with phytobezoar. It was extracted successfully. Patient was put on long-term PPIs and prokinetics along with suitable dietary modifications. including a blended food diet for two weeks and subsequent graded increase to regular food. She was advised to eat only in sitting position.

DISCUSSION
The diagnosis, management and treatment of bezoars remains a difficult task for patients and healthcare professionals. Esophageal phytobezoars usually need endoscopic removal under general anaesthesia with a rigid endoscope or fragmentation so that the smaller fragments pass distally.2 There has been a case report of successful treatment with pancreatic enzyme preparation.3 Primary esophageal phytobezoars are extremely rare with less than 20 cases reported in English literature. There is no other recorded case in review of the English literature in which such a conservative regimen has enabled a subsequent successful extraction of phytobezoar from the esophagus at a later stage. This seems to be the first reported case of a successful extraction of phytobezoar of the esophagus at a subsequent date following a failed first attempt.

References:

1. Qureshi SS. Esophageal bezoar in a patient with normal esophagus. Indian J Gastroenterol 2005;24:38
2. Walker-Renard P. Update on the medicinal management of phytobezoars. Am J Gastrenterol 1993;88:1663-6
3. Gupta R, Share M, Pineau BC. Dissolution of an esophageal bezoar with pancreatic enzyme extract. Gastrointest Endosc 2001;54:96-9