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Wednesday, July 9, 2014

Ever heard about lactobezoars?


A bezoar is a conglomeration of partially digested or undigested foreign material in the digestive tract. These masses most often form in the stomach, but are occasionally found in the small intestine and the colon, or sometimes even in the rectum. Depending on their location, bezoars may prove dangerous or not. They occasionally cause no symptoms at all, but their presence can also lead to severe complications, such as intestinal obstruction or even perforation. 

Bezoars are classified into several main types, named according to the materials from which they are composed. Phytobezoars consist of plant material, whereas trichobezoars (I mentioned them a while ago in the post on trichotillomania) are masses of ingested hair. But would you believe that curdled milk can also turn into a life-threatening bezoar?

A lactobezoar is a pathological conglomeration of half-digested milk and mucus - or, to put it simply, a large clot of milk curds - which forms in the stomach or small intestine of milk-fed infants, often causing obstruction. It's a fairly rare disorder that usually strikes prematurely born infants with a low birthweight, who are being given concentrated formula feeds containing lots of calories and protein. Basically, the immature digestive tract doesn't always handle these calorie-dense and high-protein feeds well. However, the incidence of lactobezoars isn't limited to preterm infants, and may be more frequent than reports suggest.

Clinically, the symptoms of a lactobezoar can include acute abdomen (sudden, severe abdominal pain), vomiting, diarrhea and/or a palpable mass in the abdomen. This condition normally occurs during the first few weeks of life; the peak incidence is between 4 and 10 days of age. Treatment involves ceasing oral feedings, administration of intravenous fluids and gastric lavage. Surgery may be necessary.

The following photo shows a lactobezoar that caused an obstruction of the terminal ileum (the final section of the small intestine) in a male infant with an extremely low birth weight, born at 26+2 weeks of gestation and weighing only 750 g at birth. The child had been receiving fortified human milk, preterm formula and supplements, and developed a lactobezoar at 12 weeks of life, with worrying abdominal symptoms that necessitated an exploratory laparotomy.




Lactobezoar blocking the ileum in a prematurely born infant. Image from: Jain et al. 2009


Surgery was performed to resolve the blockage and remove a section of necrotic bowel. The infant survived the operation and had no postoperative complications. However, he died on day 142 of life due to respiratory failure from severe chronic lung disease.


Literature:

Heinz-Erian P, Gassner I, Klein-Franke A, Jud V, Trawoeger R, Niederwanger C, Mueller T, Meister B, Scholl-Buergi S. (2012) Gastric lactobezoar - a rare disorder? Orphanet J Rare Dis. 7: 3.


Jain A, Godambe SV, Clarke S, Chow PC (2009) Unusually late presentation of lactobezoar leading to necrotising enterocolitis in an extremely low birthweight infant. BMJ Case Rep. 2009: bcr03.2009.1708.



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