Esophageal bezoar

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CJEM 2008;10(6):574

Following severe head trauma, an 18-year-old man was sedated using propofol and remifentanil and was put on mechanical ventilation. Enteral nutrition was initiated soon after admission via a nasogastric tube. On day 23, a major regurgitation was noted. An obstructive mass in the lower part of the esophagus was suspected after a careful opacification (Fig. 1).

Fibreoptic esophagoscopy revealed a large, yellowish and firm mass obstructing the lower esophagus (Fig. 2) that was consistent with enteral nutrient accretion. After 2 difficult attempts, the bezoar was fragmented endoscopically. No other material was found in the stomach.

The occurrence of a bezoar in a normal esophagus is exceptional. Several factors can potentially contribute to such a condition in critically ill patients. Gastroparesis and gastroesophageal reflux are frequently seen following traumatic brain injury. Additional factors include the administration of gastro-protective medications (e.g., antacids or sucralfate) or medications that impair gastrointestinal motility (e.g., morphine).1 Enteral nutrition, particularly if enriched in proteins, may also play a role, as occurred in this case.

Endoscopy is the mainstay of treatment for an esophageal bezoar. Pancreatic enzymes, or even Coca-Cola, have been proposed as agents that could dissolve large gastric or intestinal bezoars.2

References

1. Qureshi SS. Esophageal bezoar in a patient with normal esophagus. Indian J Gastroenterol 2005;24:38.
2. Chung YW, Han DS, Park YK, et al. Huge gastric diospyrobezoars successfully treated by oral intake and endoscopic injection of Coca-Cola. Dig Liver Dis 2006;38:515-7.