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Calabar Journal of Health Sciences

Case Report

Pseudo bezoar in an elderly man

Anietimfon U. Etiuma1, Chidiebere Peter Echieh1, Chimaobi I. Nwagboso1, Stephen Omirigbe Ogbudu1,
Arnold Anietimfon Etiuma1
Department of Surgery, University of Calabar, Calabar, Nigeria.
1

ABSTRACT
Indigestible intra-gastric foreign bodies are encountered in the mentally deranged, transporters of illicit
drugs or those desiring weight control. They are often complicated by obstruction, migration, or perforation.
Pseudobezoars are indigestible objects introduced intentionally into the digestive system. They may be indicated
in bariatric practice for control of obesity. We present an 87-year-old man managed for a 2-year history of burning
*Corresponding author: epigastric pain, aggravated by lying down and relieved by antacids. He had associated reflux symptoms for which
Chidiebere Peter Echieh, he adopted lifestyle modifications. He had an upper gastrointestinal endoscopy which showed a stone attached
to the anterior wall of the body of the stomach with associated pseudo-pouch formation. Mucosal overgrowth
Department of Surgery,
on the stone could be noted. Attempts at endoscopic retrieval failed as the stone could not be dis-impacted from
University of Calabar, Calabar,
its lodgement in a mucosal pouch. He had a laparotomy and gastrotomy for retrieval. A piece of stone, identified
Nigeria. as granite, which measured 2 × 2 × 2.5 cm was retrieved from the stomach with accompanying formation of the
[email protected] mucosal pouch. Mucosal response, which may include overgrowth, could be an initial step in the migration of
intra-gastric foreign bodies.

Received : 05 July 2021 Keywords: Intra-gastric foreign body, Endoscopy, Mucosal reaction
Accepted : 05 November 2021
Published : 29 April 2022

DOI
INTRODUCTION
10.25259/CJHS_29_2021
Several intra-gastric foreign bodies have been reported in the literature. They are commonly
Quick Response Code: found in mentally deranged people, transporters of illicit drugs, or those who desire weight
control. Pseudobezoars are indigestible objects introduced intentionally into the digestive
system. They are often introduced for control of obesity in medical scenarios. We report a case
of pseudobezoar resulting from the ingestion of a lump of stone for fetish reasons. This case
is peculiar because the attendant peptic symptoms were misdiagnosed as peptic ulcer disease
for several years. We also present our management challenges leading to the abandonment of
endoscopic retrieval.

CASE REPORT
An 87-year-old man presented to us with a 2-year history of epigastric pain. He is a retired
military man who has been having complaints of nonspecific upper abdominal discomfort
described as a burning pain. Pain was intermittent, aggravated by lying down, and relieved by
ingestion of over-the-counter antacids. He had associated reflux symptoms for which he had
adopted lifestyle modifications to reduce the occurrence of reflux during sleep. He had no history
of treatment for mental and behavioral illness. Furthermore, no complaints relating to his mood,

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 Etiuma, et al.: Intra-gastric granite

thoughts, experiences, and behavior. He had no history of a Grade IV gastroesophageal flap valve. Competence in
stone formation in the urinary or biliary system. He had a laparoscopic intervention was not available in the firm.
history of bladder outlet obstruction secondary to benign Hence, patient had a laparotomy and gastrotomy. The
prostatic hyperplasia. Physical examination elicited vague
tenderness in the epigastric region. However, there was no
evidence of peritonitis.
He had not had upper gastrointestinal endoscopy done
prior to present admission. For his complaints of epigastric
pain and reflux symptoms, he had an upper gastrointestinal
endoscopy which showed a concretion attached to the
anterior wall of the body of the stomach [Figure 1]. The stone
was fixed and could not be moved by scope. A close-up view
showed mucosal overgrowth on the stone creating a mucosal
pouch [Figure  2]. Attempts to dislodge the stone from the
mucosal pouch, using a water jet and by probing with the
endoscope, were not successful. Attempts at endoscopic
retrieval were abandoned because of the risk of perforation as
the stone could not be easily dis-impacted from its mucosal
pouch. A retroflexed endoscopic view of the cardia [Figure 3]
showed an incompetent lower oesophageal sphincter with Figure 3: A retroflexed view of the gastro-esophageal junction.

Figure 4: Extraction of foreign body.

Figure 1: Intra-gastric foreign body.

Figure 2: Formation of mucosal pouch. Figure 5: Dimension of the foreign body.

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 Etiuma, et al.: Intra-gastric granite

intra-operative finding was a stone that was 2 × 2 × 2.5 cm Pseudobezoars are indigestible objects introduced
[Figures 4 and 5]. This stone was attached to the anterior wall intentionally into the digestive system. They are often
of the stomach with mucosa growing unto the stone forming introduced for control of obesity in medical scenarios. We
a mucosal pouch. The gastrotomy was repaired in two layers. report a case of pseudobezoar resulting from the ingestion
In addition, he had a partial fundoplication for control of his of a lump of stone for fetish reasons. This case is peculiar
gastro-oesophageal reflux disease. Post-operative recovery because the attendant peptic symptoms were misdiagnosed
was uneventful. On recovery from surgery, the intra- as peptic ulcer disease for several years. This misdiagnosis
operative findings were discussed with the patient who then continued until the patient was referred for OGD where a
admitted to deliberately swallowing the stone over 10 years gastrolith was visualized. Attempts to retrieve the foreign
ago, for fetish fortification in wartimes. body endoscopically failed because it was firmly attached
The patient is alive and satisfied with the outcome of his to a mucosal pouch on the anterior wall of the stomach.
surgery. He has been followed up in the outpatient clinic for 2 Consent for laparotomy, retrieval, and anti-reflux procedure
months. He has relief from the epigastric pains and the reflux was obtained and we proceeded with open retrieval.
symptoms. Physical examination during his follow-up visits Earlier reports of prolonged intragastric foreign bodies
did not reveal any epigastric tenderness. report alteration of the foreign body with exposure to
gastric acids and bile salts[1,3] however, here we noted the
DISCUSSION formation of the mucosal pouch in response to prolonged
intra-gastric foreign body. We argue that mucosal reaction
Intracorporal foreign bodies could result from ingestion, which could include mucosal irritation or pouch formation
implants, or spontaneous concretion. Several intra alimentary could be the initial step in the series of events leading
foreign bodies have been reported in the literature.[1-7] They to perforation or migration of foreign bodies. Hence
are commonly found in people who are mentally deranged, migration of gut foreign bodies may not result from
practice illegal transport of illicit drugs or desire weight denudation of the viscera but an active extrusion process.
control. Upper gastrointestinal foreign bodies, in particular, are This could explain instances of migration in the absence of
often sequel to ingestion in children or patients with mental or clinical perforation.
behavioral illness. These rarely require surgical intervention.
However, in about 20% of patients, ingested foreign bodies The stone was identified as granite, chemical analysis of
warrant retrieval to avoid the occurrence of complications.[4] the stone could not be done. We believe that the mucosal
pouching could have been the initial process of possible
Current guidelines on this subject[8,9] are based on low level perforation and extrusion of the stone as it could not progress
of evidence which includes results from large series, reports downstream. We recommend attempts at endoscopic
from recognized experts, and few randomized trials.[9] This retrieval of foreign body however if the foreign body is sharp
is due to a dearth of data from well-designed prospective or has rough surfaces that may be attached to the gut wall,
trials.,[9,10] On making a diagnosis of foreign body ingestion, risks of perforation should be considered.
the managing physician has to decide on the need for
intervention and the required urgency.
CONCLUSION
Factors that influence management of ingested foreign bodies
include the clinical condition of the patient; the size, shape, Intra-gastric foreign bodies could result from several
and anatomic location of the ingested material. Bulky organic reasons. Development of gastric mucosal pouch in response
foreign bodies which can be broken down into smaller to intragastric foreign bodies could be the initial step to
pieces, within the gut, may be removed in piecemeal. Foreign perforation and migration.
bodies with risk of perforation warrant urgent intervention.
Although oesophagogastroduodenoscopy (OGD) remains Declaration of patient consent
the goal standard for retrieval of ingested foreign bodies,
Patient’s consent not required as patients identity is not
caution should be taken during endoscopic removal of
disclosed or compromised.
foreign bodies with sharp edges to avoid longitudinal tear
of the esophagus. Adjuncts to endoscopic retrieval of sharp
objects include the use of over-tubes, transparent cap, and Financial support and sponsorship
latex rubber hood.8 In this patient, a cold polypectomy Nil.
snare was used to attempt retrieval, but because the base
was not pedunculated and a lateral traction did not displace Conflicts of interest
the object, we abandoned the procedure and opted for open
retrieval. There are no conflicts of interest.

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 Etiuma, et al.: Intra-gastric granite

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