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Burgos-Torres MDM, Molina-Lopez VH, Perez Cruz NM, Perez Del Valle C, Sorrentino J. Multivitamin-Induced Pharmacobezoar: A Rare Entity of Large Bowel Obstruction. Cureus 2023; 15:e41688. [PMID: 37441102 PMCID: PMC10334454 DOI: 10.7759/cureus.41688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 07/15/2023] Open
Abstract
The term bezoar refers to a foreign object found like a mass of concretion in the gastrointestinal tract that results from an accumulation of undigested material. When the composition of the ingested material is a medication, it is known as a pharmacobezoar. A rare complication from pharmacobezoar is large intestinal obstruction. Here we present the case of a 77-year-old male who presented with progressive abdominal distension, involuntary guarding, and large bowel obstruction. Abdominal imaging studies were remarkable for radiopaque objects of uncertain etiology in the transverse colon and rectal ampulla. The patient underwent colonic decompression by sigmoidoscopy, where the pills were identified by direct visualization. He later underwent endoscopic removal of the pharmacobezoars. A detailed medication review identified the culprit to be multivitamins. This case portrays an unusual etiology of large bowel obstruction. At this moment, no cases have been reported of multivitamins as the culprit of pharmacobezoar with subsequent development of large bowel obstruction.
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Affiliation(s)
| | | | | | | | - Jose Sorrentino
- General Surgery, VA Caribbean Helathcare System, San Juan, PRI
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Mégarbane B, Gharnaout N, Djebrani Oussedik N. Pharmacobezoar: a rare cause of body packing misdiagnosis. Clin Toxicol (Phila) 2023; 61:312-314. [PMID: 37017708 DOI: 10.1080/15563650.2023.2192387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
INTRODUCTION Diagnosis of body packing based on the misinterpretation of imaging is rare. CASE REPORT An unaccompanied 55-year-old woman presented with uncontrolled vomiting in the airport transit area. An abdominal radiograph and computed tomography scan revealed multiple radiopaque foreign bodies in the colon. History was unobtainable due to the language barrier. The patient was referred to our institution as a body packer who required surgical extraction of the packets. In the absence of symptoms, she was managed conservatively with antiemetic drugs and whole bowel irrigation. The final diagnosis was radiopaque pharmacobezoars caused by an over-the-counter barium-containing anticancer medication in the setting of severe hypokalemia-associated paralytic ileus following post-chemotherapy vomiting. After the correction of her potassium concentration, the patient was discharged and resumed her trip. CONCLUSION Clinicians should be warned that pharmacobezoars might be mistaken for drug packets on abdominal imaging leading to body packing misdiagnosis.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, APHP, Paris, France
- INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Nawel Gharnaout
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, APHP, Paris, France
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McCarthy R, Coleman M. Recurrent intoxication due to clomipramine pharmacobezoar. Anaesth Rep 2023; 11:e12230. [PMID: 37216042 PMCID: PMC10196812 DOI: 10.1002/anr3.12230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/24/2023] Open
Affiliation(s)
- R. McCarthy
- Departments of Anaesthesia and Intensive Care MedicineUniversity Hospital LimerickLimerickIreland
| | - M. Coleman
- Departments of Anaesthesia and Intensive Care MedicineUniversity Hospital LimerickLimerickIreland
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Abstract
Objectives: There have been few studies of pharmacobezoar formation, but they can be an important contributor to overdose toxicity. Pharmacobezoars may explain the delayed peak or "double hump" pharmacokinetics, which were noted in previous case reports with delayed toxicity of acetaminophen (APAP). We validated the presence of APAP bezoar formation in a controlled modified in vitro environment simulating acute APAP overdose.Methods: This study involved the APAP and control groups (ferrous sulfate and chlorpheniramine). The APAP study group contained three subgroups of APAP with different dosage, i.e., 25 g (50 tabs)/37.5 g (75 tabs)/50 g (100 tabs). The positive control group containing ferrous sulfate, i.e., 15 g (50 tabs), has been reported previously to form pharmacobezoars in overdose. The negative control group containing chlorpheniramine, i.e., 200 mg (50 tabs), has not been reported to form pharmacobezoars in previous case studies. Tablets from each study group were placed into a separate pig stomach. Each stomach contained 28 ml USP standard simulated gastric acid. The stomach was placed in a plastic box filled with water maintaining at 37 °C. Each test group was examined for 4 h in the stomach. The primary outcome was the presence of clump formation. Positive clump formation was defined as tablets sticking together and the ability to maintain shape upon dissecting the pig stomach and lifting with fingers. Tablet clumps would then undergo dissolution testing with subsequent analysis of dissolution profiles.Results: Formation of tablets clumps was confirmed in APAP overdose in the in vitro environment. Clumps were noted to be present in the 37.5 g and 50 g APAP groups, while 25 g APAP was unlikely to form clumps. The dissolution profile of clump demonstrated slower release without reaching plateau at 60 min, as compared to corresponding individual tabs of APAP. f1 and f2 analyses showed the dissolution profile of clump was different compared to that of referenced individual tab.Conclusions: APAP clump formation was confirmed in acute overdose of 37.5 g or more. Dissolution tests revealed delayed and steady release of tablet residue from the clumps, which could explain prolonged or delayed toxicity in large APAP overdose.
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Affiliation(s)
- Yu Kwan Li
- Accident and Emergency Department, Princess Margaret Hospital, Hong Kong, Hong Kong SAR
| | - Ka Fung Lam
- Accident and Emergency Department, Princess Margaret Hospital, Hong Kong, Hong Kong SAR
| | | | - Anselm Wong
- Department of Emergency Medicine, Victorian Poisons Information Centre, Austin Toxicology Service, Austin Health, Melbourne, Australia.,Department of Medicine and Radiology, Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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Gavala A, Manou D, Psalida V, Nystatzaki M, Mavrogiannis C, Alevizopoulos G, Myrianthefs P. Methadone Gastrobezoar in a Psychiatric Patient Presented in Coma. Indian J Crit Care Med 2017; 21:796-798. [PMID: 29279645 PMCID: PMC5699012 DOI: 10.4103/ijccm.ijccm_17_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 43-year-old psychiatric patient was transferred in coma and hypercapnic respiratory failure at the emergency department. He was intubated for airway protection and transferred to the Intensive Care Unit (ICU). Abdominal X-ray revealed a radiopaque mass; a pharmacobezoar was suspected and confirmed by gastroscopy; one large in the stomach fundus and a smaller one in the pylorus. Gastric lavage through the gastroscope and administration of gastro-kinetic drugs and laxatives were able to dilute the bezoars. Tablets retrieved from the stomach identified as methadone and toxicological tests of the gastric fluid confirmed the presence of methadone as the only organic chemical compound. The patient was extubated on the 7th day and released from the ICU on the 10th day under psychiatric consultation having normal vital signs. Methadone gastric bezoar may lead to persistent intoxication, respiratory failure, and coma requiring ICU care. Diagnosis may be difficult and a high index of suspicion is needed.
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Affiliation(s)
- Alexandra Gavala
- Department of Intensive Care Unit, Kaliftaki, 14564, Nea Kifissia, Greece
| | - Despoina Manou
- Department of Gastrenterology, Kaliftaki, 14564, Nea Kifissia, Greece
| | - Vasiliki Psalida
- Department of Intensive Care Unit, Kaliftaki, 14564, Nea Kifissia, Greece
| | - Maria Nystatzaki
- Department of Psychiatry at "Agioi Anargyroi" General Hospital, Kaliftaki, 14564, Nea Kifissia, Greece
| | - Christos Mavrogiannis
- Department of Gastrenterology, Kaliftaki, 14564, Nea Kifissia, Greece.,Faculty of Nursing, School of Health Sciences, National and Kapodistrian University of Athens, Greece
| | - George Alevizopoulos
- Department of Psychiatry at "Agioi Anargyroi" General Hospital, Kaliftaki, 14564, Nea Kifissia, Greece.,Faculty of Nursing, School of Health Sciences, National and Kapodistrian University of Athens, Greece
| | - Pavlos Myrianthefs
- Department of Intensive Care Unit, Kaliftaki, 14564, Nea Kifissia, Greece.,Faculty of Nursing, School of Health Sciences, National and Kapodistrian University of Athens, Greece
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Sato C, Kamijo Y. An unexpected prolonged coma due to a pharmacobezoar formed from Vegetamine A® tablet ingestion. Acute Med Surg 2014; 2:60-63. [PMID: 29123693 DOI: 10.1002/ams2.58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 05/03/2014] [Indexed: 11/08/2022] Open
Abstract
Case A 49-year-old man ingested massive quantities of Vegetamine A® tablets that contain two anticholinergic agents in addition to phenobarbital. The patient remained in an unexpectedly prolonged coma 4 days post-hospitalization. An acute gastroscopy revealed a pinkish-white pharmacobezoar on the lesser curvature of the stomach, which was extracted using a net. Direct hemoperfusion and treatment with multiple-dose activated charcoal was then initiated. Phenobarbital serum concentrations eventually decreased, resulting in complete recovery of the patient. Outcome On day 30, the patient was transferred to the Psychiatric Department. Conclusion An intragastric pharmacobezoar should be suspected in patients with promoted and prolonged toxicity or if high serum concentrations of agents indicate their continuous absorption.
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Affiliation(s)
- Chie Sato
- Department of Emergency and Critical Care Medicine, School of Medicine Kitasato University Sagamihara Japan
| | - Yoshito Kamijo
- Department of Emergency and Critical Care Medicine, School of Medicine Kitasato University Sagamihara Japan
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Briggs AL, Deal LL. Endoscopic removal of pharmacobezoar in case of intentional potassium overdose. J Emerg Med 2013; 46:351-4. [PMID: 24113476 DOI: 10.1016/j.jemermed.2013.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 05/01/2013] [Accepted: 08/14/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hyperkalemia is a potentially life-threatening electrolyte abnormality commonly seen in the emergency department (ED). Intentional overdose of potassium supplements is an uncommon occurrence. OBJECTIVE This case illustrates a novel approach to treatment of pharmacobezoar with esophagogastroduodenoscopy (EGD) and demonstrates its effectiveness in the setting of extended-release potassium chloride overdose. CASE REPORT A 44-year-old female presented to the ED with intentional ingestion of an unknown amount of extended-release potassium chloride (K-Dur®) tablets and alprazolam (Xanax®). The patient's serum potassium was initially 7.3 mmol/L and she was treated with standard treatments, including albuterol, calcium gluconate, insulin, dextrose, and sodium bicarbonate. Radiographic investigation showed a pharmacobezoar in the gastric fundus. Treatment was then augmented with whole bowel irrigation (WBI) using polyethylene glycol solution via nasogastric tube. Patient did not tolerate the nasogastric tube, became combative with increasing alteration in her level of consciousness, and WBI therapy was stopped. After discussion with the gastroenterologist, the patient was treated with EGD to remove the pharmacobezoar. The EGD was successful in the removal of the pharmacobezoar and the patient's potassium normalized without complications. CONCLUSIONS We recommend that in cases of suspected or confirmed potassium drug bezoar in the stomach, physicians consider EGD for removal. This allows for normalization of potassium level while preventing adverse sequelae.
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Affiliation(s)
- Albert L Briggs
- Department of Emergency Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Lisa L Deal
- Department of Emergency Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
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Kotzampassi K, Grosomanidis V. Pharmacobezoar in an obese patient with intragastric balloon: a case revealed at endoscopy. Clin Obes 2012; 2:168-70. [PMID: 25586252 DOI: 10.1111/cob.12003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 11/09/2012] [Accepted: 11/13/2012] [Indexed: 11/28/2022]
Abstract
Pharmacobezoar formation is a very rare complication that occurs in cases of altered gastrointestinal motility or to a background of disturbed anatomy of the gastrointestinal tract. The case of an obese and depressed patient treated by an intragastric balloon for weight loss, who was revealed to have a pharmacobezoar during endoscopy for early balloon removal, is presented. The possible causes of pharmacobezoar formation in such a patient treated with an intragastric balloon are discussed.
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Affiliation(s)
- K Kotzampassi
- Department of Surgery, Aristotle's University of Thessaloniki, Thessaloniki, Greece
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