Novel approach to managing two enormous bezoars with successive snare-tip electrocautery: A case report

Abstract

BACKGROUND

Gastric bezoars are indigestible masses that can lead to gastrointestinal obstruction and ulceration. Standard treatments include endoscopic mechanical lithotripsy with a polypectomy snare and Coca-Cola dissolution therapy or a combination of both approaches. However, giant bezoars frequently require multiple treatment sessions and extended hospital stays. Additionally, snare-based mechanical fragmentation may be limited by factors such as bezoar size, shape, density, slipperiness, and restricted working space. In cases where refractory giant bezoars are unresponsive to traditional methods, surgical intervention is often necessary.

CASE SUMMARY

A 57-year-old male with a history of type 2 diabetes presented with severe epigastric pain and vomiting. Endoscopy revealed two large phytobezoars and a gastric ulcer. Initial attempts at mechanical fragmentation with a polypectomy snare and Coca-Cola ingestion for dissolution were unsuccessful due to the large size and complex structure of the bezoars. An innovative approach using snare-tip electrocautery was then employed. It successfully penetrated the slippery, hard surface of the bezoars and fragmented them into smaller pieces. The patient was subsequently treated with Coca-Cola ingestion, enzyme supplements, and proton pump inhibitors. He was discharged without complications following the endoscopic sessions.

CONCLUSION

Snare-tip electrocautery is a safe, cost-effective, and minimally invasive alternative for managing large, refractory gastric bezoars. This is a valuable option in resource-limited settings.

Key Words: Bezoars; Electrocautery; Phytobezoars; Endoscopic removal; Snare-tip; Case report

Core Tip: Snare-tip electrocautery provided precise and efficient fragmentation of refractory bezoars, which reduced the need for surgery. Snare-tip electrocautery may be particularly useful in cases unresponsive to conventional treatments.

INTRODUCTION

Bezoars are foreign bodies formed within the gastrointestinal tract due to the aggregation of undigested material. They are categorized into four distinct types based on their composition: Phytobezoars; trichobezoars; pharmacobezoars; and lactobezoars[1]. Phytobezoars are prevalent in the stomach. Bezoars exceeding 3 cm in size pose an elevated risk of gastric ulcers and intestinal obstruction. Ulcers are often localized to the angulus of the stomach due to friction from the bezoar. Bezoars are treated with endoscopic mechanical fragmentation and the use of carbonated beverages such as Coca-Cola. Large bezoars typically require combination therapy consisting of multiple treatments over an extended period. The outcomes can be unsatisfactory, especially in cases of symptomatic gigantic bezoars, which often require surgical intervention. Herein, we present the case of two massive stomach bezoars complicated by symptoms of gastric outlet obstruction that were successfully managed using unconventional snare tip electrocautery.

CASE PRESENTATION

Chief complaints

A 57-year-old Asian male presented to our emergency department with severe epigastric pain.

History of present illness

The patient had a medical history of type 2 diabetes. He reported experiencing postprandial epigastric discomfort persisting for over 3 months. Recently, the patient had also began experiencing episodes of postprandial vomiting, even with the ingestion of water.

History of past illness

The patient’s past medical history is unremarkable, with no significant illnesses, hospitalizations, or surgical procedures reported.

Personal and family history

Family history of Hypertension in his father.

Physical examination

Physical examination revealed abdominal distension with tenderness localized to the epigastric region.

Laboratory examinations

Laboratory analysis indicated the presence of microcytic anemia, as evidenced by hemoglobin at 9.4 g/dL (normal range: 13-18 g/dL) and mean corpuscular volume of 72.7 fl (normal range: 85.6-102.5 fl).

Imaging examinations

Kidney, ureter, bladder X-ray revealed gastric distension with fecal-like material present. Esophagogastroduodenoscopy revealed the presence of two large phytobezoars, each measuring 8 cm in diameter. They were situated within the fundus and body of the stomach. A sizable deep ulcer (Forrest IIb, 5-6 cm) located in the angular incisure extending into the antrum area was also detected (Figure 1A and B).

Figure 1 Esophagogastroduodenoscopy. A: Two large phytobezoars, each 8 cm in diameter, were located in the fundus and body of the stomach; B: A Forrest IIb ulcer (5-6 cm in size) was located at the angular incisure and extended into the antrum area.

FINAL DIAGNOSIS

Phytobezoar and ulcer.

TREATMENT

Initial attempts at mechanical lithotripsy utilizing a 33-mm round snare (extra-large rounded, single-use polypectomy snare; Boston Scientific, Marlborough, MA, United States) and raptor forceps were unsuccessful due to the slippery structural density of the bezoar, which prevented effective anchoring of the snare. Subsequent interventions employed the snare tip for electrocautery [forced coagulation mode, effect 2, 35-50 W (VIO 300D; Erbe, Marietta, GA, United States)] extended by approximately 2-4 mm to enable precise bezoar fragmentation while minimizing mucosal contact (Figure 2). The bezoar was reduced to fragments smaller than 2 cm to mitigate the risk of small intestine obstruction (Video).

Figure 2  Snare-tip electrocautery successfully fragmented the bezoar.

During hospitalization, the patient’s intake consisted solely of diet Coca-Cola (600-1000 mL every 6 hours) and a digestive enzyme supplement. Proton pump inhibitor therapy was initiated to address ulceration. Eight days after the initial treatment, a follow-up esophagogastroduodenoscopy demonstrated incomplete dissolution of the bezoar. There was evidence of the original unfragmented mass and the aggregation of fragmented remnants into a smaller concretion.

OUTCOME AND FOLLOW-UP

Subsequent endoscopic sessions addressed the remaining unfragmented bezoar. The day following the final endoscopic fragmentation, the patient was discharged uneventfully.

DISCUSSION

Coca-Cola is the primary treatment for the dissolution of gastric bezoars[2]. Alternatively, combined endoscopic mechanical fragmentation using lithotripters, snares, or forceps may be employed. Giant bezoars refractory to conventional treatments often require surgical intervention. Argon plasma coagulation (APC) and electrohydraulic lithotripsy have also been used to manage massive bezoars. However, only limited case series data and specific procedural reports are available[3,4].

During APC or laser lithotripsy treatment, accurately assessing the depth of fragmentation can be challenging, and the soft nature of the APC probe complicates effective manipulation of the bezoar. Similarly, electrohydraulic lithotripsy introduces a significant amount of water into the gastric lumen, which can obscure the visualization of the bezoar and surrounding mucosa, increasing the risk of gastric mucosal injury. Moreover, these methods often require additional tools, such as snares or forceps, to fragment debris effectively. Both techniques not only fail to fragment bezoars independently and are time-consuming but also pose an increased risk of mucosal injury due to limited visualization of treatment depth.

In this case, snare-tip electrocautery offers a viable alternative for managing intractable bezoars, particularly in resource-limited settings where advanced equipment may not be available. Extending the snare tip approximately 0.2-0.4 cm beyond the snare sheath, similar to techniques used with a longer needle knife, allows for precise visualization of the cutting depth and helps prevent mucosal injury. Additionally, the snare sheath facilitates repositioning of the bezoar in challenging angles, enhancing procedural effectiveness. The electrocautery function reduces the stickiness of clay-like bezoars, which can otherwise impede fragmentation, enabling more efficient treatment. The same snare can also be used to fragment residual bezoar debris effectively.

CONCLUSION

Snare-tip electrocautery is an effective, safe, and cost-efficient non-surgical intervention for large, refractory bezoars. Its versatility enables precise depth control in confined spaces, and the procedure time is reduced. Snare-tip electrocautery is a valuable endoscopic option for managing refractory bezoars.