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GASTRIC PHYTOBEZOAR IN A SCHIZOPHRENIC PATIENT

Haribhakti Seba Das*, Ks Sethna+, Kaushal Vyas*,Naresh Kumar Biyani#, Pravin Rathi**, Prabha Sawant***
*Resident; **Lecturer; ***Prof. and Head; Department of Gastroenterology, +Associate Professor of Surgery; #Resident in Surgery, LTMMC and LTMG Hospital, Sion, Mumbai.

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We report a large gastric phytobezoar in a male schizophrenic patient which was removed surgically.

INTRODUCTION

Bezoars are retained concretions of animal or vegetable materials in the gastro-intestinal tract. We report a large gastric phytobezoar in a schizophrenic patient who was on antipsychotic therapy for many years.

CASE REPORT

A 60 year old man presented with the history of dull aching, non-radiating pain in the epigastrium since 20 years. He used to feel a lump off and on in mid upper abdomen. He had intermittent vomiting. His appetite was good, but complained of early satiety, post-prandial fullness and weight loss. He had no past history of any gastrointestinal surgery. Patient had auditory hallucinations and was diagnosed to have paranoid type of schizophrenia. He was on antipsychotic drugs for last 30 years. On direct questioning he gave history of improper mastication of food. There was no history of trichophagia or trichotilomania. Physical examination was unremarkable. There was no baldness. Per abdominal examination revealed a lump in the epigastrium of 5 x 4 cms in size, globular in shape, hard in consistency with side to side mobility. It was non-tender and dull on percussion. Upper Gastrointestinal endoscopy revealed a large hard black bezoar in the fundus. It could not be fragmented with biopsy forceps and dormia basket. The patient was subjected for surgical gastrostomy in view of its large size and hard consistency. It was removed surgically and the postoperative course was uneventful. On gross examination the bezoar was 5 x 8 x 3 cms; hard in consistency with serrated surface (Fig. 1). The patient was discharged with prokinetics along with proper psychiatric evaluation and treatment.

Fig 1. Photograph of gastric phytobezoar removed surgically

DISCUSSION

Bezoars are foreign bodies found mainly in the stomach, which are composed of plant and vegetable fibers (phytobezoars), persimmons (disopyrobezoars), hair (trichobezoars), dead ascaris (worm bezoar), milk (lactobezoars) or other substances.[1-3] Phytobezoars are the commonest variety to be reported and occurs in patients with gastric stasis like systemic sclerosis, long standingdiabetes and gastric surgery. Treatment with high doses of alpha-adrenergic agonists, anti-cholinergics, and gastric surgery impairs the gastric motility. Antipsychotic drugs alter the gastric emptying due to its anti-cholinergic property. Poor mastication and consumption of large amount of indigestible solids may precipitate bezoar formation, which may have played a role in the reported case. Ingestion of large amount of citrus food containing a high amount of cellulose may predispose to bezoar formation in patients with prior gastric surgery. [4] Current treatment of bezoars includes medical treatment with enzymes, prokinetic agents and endoscopic management. Endoscopic management includes enzymatic dissolution by injecting cellulose, use of water jet, drill device, dormia basket, mechanical lithotriptor or electrohydraulic lithotripsy.[5] Wang et al have devised a bezotriptor based on the principle of Sohendra lithotriptor used for mechanical lithotripsy of bile duct stones. [6] They have reported 18 large bezoars in 15 patients, which were successfully fragmented with the bezotome and bezotriptor. But sometimes disruption is not possible in large and very hard bezoars and they need surgery. We report a rare case of a large, hard gastric phytobezoar in a schizophrenic patient with long history of antipsychotic therapy. So modification of dietary habits is needed in patients with antipsychotic drugs.

REFERENCES

1.Andrus CH, Ponsky JL. Bezoars:classification, pathophysiology, and treatment. Am J Gastroenterol 1988; 83 : 476-8.

2.Barkin JS, O’Phelan CA. Advanced therapeutic endoscopy. New York : Raven Press. 1990; 32-6.

3.DeBakey M ,Ochsner A. Bezoars and concretions : a comprehensive review of the literature with an analysis of 303 collected cases and a presentation of eight additional cases. Surgery 1939; 5 : 132-60.

4.Rubin M, Shimonov M, Grief F, Rotestein Z, Lelcuk S. Phytobezoar : a rare cause of intestinal obstruction. Dig Surg 1998; 15 : 52-4.

5.Kuo JY, Mo LR, Tsai CC, Chou CY, Li n RC, Chang KK. Non-operative treatment of gastric bezoars using electrohydraulic lithotripsy. Endoscopy 1999; 31 : 386-8.

6.Wang YG, Seitz U, Li ZL, Sohendra N, Qiao XA. Endoscopic management of huge bezoars. Endoscopy 1998; 30 : 371-4.

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