Patient: 63-year-old female from Massachusetts
Symptoms: The patient visited the emergency department because nausea, vomiting, and loss of appetite continued for about a month. She told doctors that she felt a burning pain in her upper abdomen and the right side of her torso, extending all the way to her back. She tried to treat these symptoms with two common over-the-counter medications for acid reflux disease, but to no avail.
In the previous year, the patient had started taking semaglutide. Semaglutide is a type of drug known as a GLP-1 receptor agonist, the same type of drug as Ozempic. These injectable drugs are used to treat type 2 diabetes and aid in chronic weight management. In this case, the woman had a history of type 2 diabetes and obesity. Since starting the medication, she has lost about 40 pounds (18 kilograms), but notably, she noted, that weight loss has accelerated over the past month.
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What happened next: Doctors took a CT scan of the patient’s abdomen and pelvis. This revealed that the bile ducts that carry bile from the liver to the gallbladder and small intestine were slightly dilated. The woman also had a “heavy stool burden,” but there were no signs of intestinal obstruction and her stomach was slightly stretched as she was carrying “semi-solids.”
To find out more, the medical team used magnetic resonance cholangiopancreatography, a non-invasive scan that examines the bile ducts, gallbladder, pancreas, and pancreatic ducts. Scans confirmed that her bile ducts were dilated and revealed a mass in her stomach that appeared to be filled with air. Doctors then used an endoscope to examine the upper gastrointestinal tract, from the esophagus to the upper part of the small intestine.
Diagnosis: An endoscopy revealed a large mass known as a gastrobezoar in the woman’s stomach. These clumps are densely packed masses of partially digested or undigested material.
Treatment: Semaglutide and other GLP-1 agonists usually cause delayed gastric emptying. This means that the stomach slows down the rate at which it empties its contents into the intestines. The woman discontinued the drug upon admission.
The next step for gastroliths is to try to dissolve the mass while it is still in the stomach. There is evidence that a good way to do this is to give the patient a soda.
“Existing evidence, primarily from case series and anecdotal experience, supports a 3-liter dose. [0.8 gallons] “Cola was ingested orally or via nasogastric tube within a 12-hour period. Whether the dissolution of gastric acid was due to acidity, carbonation, or another mechanism is not well understood,” doctors wrote in the case report.
The patient had a history of diabetes, so Diet Coke was administered. She also didn’t like soda, so her usual 3 liter soda prescription was reduced to 1.5 liters (0.4 gallons). On the second day of starting this treatment, the patient felt a “pulling” sensation in the abdomen, followed by relief of nausea and abdominal discomfort. Endoscopy revealed that the bezoar was not stuck in the stomach.
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The woman was then transitioned to a normal diet in the hospital, and by the time she was discharged from the hospital, her nausea, vomiting, and abdominal pain were gone. She did not restart semaglutide, but was prescribed acid reflux medication to take daily. She reported an increase in appetite after discharge and some weight regain over the next few months. Her abdominal symptoms did not recur several months after discharge.
What makes this case unique is that gastrobezoars are fairly rare, the report notes. These are found in less than 0.5% of cases during upper gastrointestinal endoscopy. The common symptoms of this disease, such as pain, nausea, vomiting, and abdominal discomfort, do not necessarily indicate the presence of bezoars in all cases, as they also appear in many of the more common diseases.
The most common type of gastrobezoar is formed of plant fibers and is called a “phytobezoar.” Eating a lot of certain foods, such as persimmons, pineapples, raisins, and celery, can increase your risk of plant gastroliths because plants contain high concentrations of indigestible components such as cellulose, lignin, and certain tannins.
However, various medical conditions, procedures, and medications can also increase the risk of gastroliths. These include anatomical changes associated with obesity or other gastric surgery, autonomic nerve damage, and drugs that slow gastric emptying, such as GLP-1. In this woman’s case, semaglutide was likely the cause of her bezoars, and discontinuing treatment helped resolve the problem.
The cola she drank also helped. Although this treatment strategy sounds strange on the surface, it is the first-line treatment preferred over physically destroying the bezoar in a patient’s stomach using an endoscope.
“Bezoars formed from food materials may initially be managed by oral administration of cola to patients in clinically stable condition,” the report said. “This intervention is generally cost-effective and carries a lower risk of complications than invasive procedures.”
For more interesting medical cases, check out our Diagnostic Dilemma archives.
This article is for informational purposes only and does not provide medical advice.
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