Cardboard bezoar complicating laparoscopic gastric bypass

Ileal bezoar causing bowel obstruction mimicking an internal hernia in a patient with Roux-en-Y gastric bypass

We presented a case of a 64-year-old female patient with a history of gastric bypass that presented with bowel obstruction due to a bezoar. She arrived at the emergency department, referring to severe abdominal pain, nausea, and vomiting. Abdominal X-ray reported gastric distention and hydro-air levels. CT scan reported swirling of the mesentery vessels and a collapsed intestinal loop, mimicking an internal hernia. Laparotomy was accomplished, which shows obstruction at 60 cm from the ileocecal valve. An enterolithotomy was performed, and a 6 × 6 cm phytobezoar was extracted. The patient had a satisfactory postoperative outcome, discharging her home on the fourth postoperative day. On a 12 month-follow up, the patient is doing well with no further complications. Gastric bypass continues to be one of the most performed bariatric procedures with low complication rates. It is important to note that not all intestinal obstructions in postoperative bariatric surgeries are due to internal hernias or adhesions. The differential diagnosis of intestinal obstruction due to bezoar must be present in patients who underwent bariatric surgery. Nutritional counseling is essential for the follow-up of patients, emphasizing fluid intake and slow chewing, as well as the use of absorbable materials for suture during the surgery.

Pica patient, status post gastric bypass, improves with change in medication regimen

The causes and origins of pica remain unknown and are the source of speculation and heated debate. Bariatric surgery patients are increasingly being observed in eating disorders treatment programs. Often associated with pregnancy, iron deficiency anemia, early development and mental retardation, pica has only recently been noted in post bariatric surgery patients, all of whom presented with pagophagia (eating of ice). Although there is literature detailing the presence of bezoars in gastric bypass patients, the association of pica, bezoars and abnormal eating behavior after bariatric surgery is still not understood completely. We present the case of a patient diagnosed with pica who underwent bariatric surgery due to a specific bezoar causing obstruction, followed by a treatment plan aimed at curbing the impulses. The patient was diagnosed to have a cardboard and paper bezoar causing gastric obstruction, which was removed endoscopically. After incomplete improvement of pica symptoms with treatment including ziprasidone, lorazepam and behavioral therapy, Saphris (asenapine) was introduced resulting in significant and complete resolution.