Gastric Phytobezoar: A Case Report

She also complained of a sensation of abdominal bloating and some subjective weight loss. She denied any fever, constipation, or diarrhea. She did not report any hematemesis or melena. Her past medical history included a Billroth II procedure with Roux-en-Y revision for an anastomotic bleed, hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and stroke with residual right-sided paraesthesias. Review of other systems was unrevealing. She was currently taking lisinopril, metformin, glipizide, clopidogrel, omeprazole, and albuterol pump. She did not have any known drug allergies. She had been smoking cigarettes for more than 20 years and admitted to occasional alcohol consumption. She also admitted to using cocaine intermittently. There was no family history of GI malignancies. On physical examination, there was mild tenderness in the epigastric area on palpation. There was no guarding or rigidity. There was no abdominal mass palpated. A succussion splash was auscultated over the upper abdomen. (The “splash,” which is heard when the stethoscope is placed over the upper abdomen and the patient is rocked back and forth at the hips, suggests retained gastric contents.) However, the succussion splash was heard soon after a meal and did not persist beyond 3 hours. Bowel sounds were heard. There was no lymphadenopathy. The balance of the physical examination was notable only for mild pallor. Laboratory tests revealed the following: hemoglobin 11 g/dL (12-16 g/dL); hematocrit 34% (37%-47%); MCV 82 fL (80.4-95.9 fL); MCH 26 pg/cell (27-31 pg/cell); MCHC 30.2 g/dL (32-36 g/dL); and RDW 14.6% (12%-15%). There were no electrolyte abnormalities, including hypokalemia and a hypochloremic metabolic alkalosis. Abdomen and pelvis CT with contrast revealed that the patient was status post partial gastrectomy. It also showed chronic stable intrahepatic and extrahepatic biliary ductal dilatation and pancreatic duct dilatation with pancreatic atrophy. Upper endoscopy was performed in view of the patient’s history of refractory PUD and multiple abdominal surgeries. It showed a normal gastric remnant, an ulcer at the anastomotic site, and a large bezoar on the gastric side of anastomosis (Figures 1 and 2). Biopsy from the mass showed vegetable fibers, confirming the diagnosis of phytobezoar. A number of factors were considered before electing first-line treatment. The patient’s symptoms were mild and she had no clinical signs and symptoms of gastric outlet obstruction (GOO). She did not have persistent epigastric pain, repeated postprandial vomiting, abdominal distention, signs of volume depletion, or weight loss. The symptoms also were not getting progressively worse. She had no complications in the form of GI perforation, peritonitis, intussusception, pancreatitis, obstructive jaundice, upper GI bleeding, or pneumatosis intestinalis. On the basis of these parameters, the decision was made to treat her conservatively with chemical dissolution. There was no indication for an endoscopic procedure. She was advised to continue with omeprazole and to drink one 12-oz can of Coca-Cola twice a day. She was also instructed to consume a diet of blended liquids (thickened soups for vegetables rather than raw vegetables) and take a soft mechanical diet. This diet was recommended for the