LETTER TO THE EDITOR

Vomiting and An Abdominal Mass ImmediatelyAfter Vaginal Delivery: An Unusual Cause

Ahmed Helmy & Hamad Al Ashgar & Ali Benmousa &

Khalid Al Kahtani

Received: 17 March 2008 /Accepted: 27 March 2008 /Published online: 20 May 2008# Springer Science + Business Media, LLC 2008

Dear Editor,Bioenteric intragastric balloons (BIB) are becoming popularand more commonly used for weight reduction after theirsafety and efficacy demonstrated in randomized controlledtrials [1, 2]. The safety of BIB during pregnancy has notbeen addressed before simply because it is not done inpregnant lady.

We are reporting a 34-year-old lady who was seen bygastroenterology team in King Faisal Specialist Hospitaland Research Centre, Riyadh, Saudi Arabia because ofepigastric pain, nausea, and repeated vomiting for 4 daysstarted after uneventful spontaneous vaginal delivery of hersecond child. She had occasional blood stained vomitus andmild fresh bleeding per rectum that was likely related to herpreviously known hemorrhoids. She is also known to havebronchial asthma, gestational diabetes mellitus, gastro-esophageal reflux disease, and had a past history ofappendectomy and removal of breast lipoma. She also gavea history of gastroscopy done in a private hospital 2 yearsearlier. Her medications included ranitidine, metoclopra-mide, ventolin inhaler, folic acid, and anusol suppository.

Clinically, she was hemodynamically stable, and hergeneral examination was unremarkable apart from being paleand mildly dehydrated. Her abdominal examination showed alarge palpable, mobile, well demarcated, non tender mass inthe center of the upper abdomen. Another pelviabdominalmass was felt and that was a subinvoluted uterus.

Laboratory work up was basically normal apart fromhemoglobin of 8.4 gm/dl with normal mean corpuscular

volume. Bedside abdominal ultrasound revealed the pres-ence of large cyst in the upper abdomen with an orifice andsurrounding calcification. Plain abdominal X-ray and CTabdomen were subsequently done and confirmed theultrasound finding where a 20×10-cm intragastric, fluid-and air-filled cystic structure seen in addition to thepelviabdominal mass which is the subinvoluted uterus(Figs. 1 and 2).

The patient underwent an urgent upper gastrointestinalendoscopy, which showed an intact intragastric balloon thatwas covered with food residue and fungal infection (Fig. 3).The balloon was removed during the procedure andsubsequently, the patient’s symptoms improved dramati-cally. We revisited the patient’s medical history, andalthough she recalled having an upper GI endoscopy 2 yearsearlier in another institution, she seemed unaware that aballoon was inserted, and gave no history of follow-up afterthat endoscopy. She also denied any upper gastrointestinalsymptoms during that period including the time ofconception.

We would like to address several issues in this case. Thefirst is the safety of BIB during pregnancy since very littleis known about that. We are only aware of a case report of apregnant lady who developed intestinal obstruction afterrupture and migration of intragastric balloon [3]. Ourpatient might be the first reported case of survived BIBthroughout pregnancy without any major complication.Second, our patient tolerated the balloon although hersymptoms were expected to worsen due to the combinedeffect of the pressure of gravid uterus and reduced gastricvolume by the balloon. Third, patients rarely forget abouttheir gastric balloons and as a result they may come withcomplications related to the long stay of the balloon. Lastly,the balloon was surprisingly missed during three antenatalobstetric ultrasound examinations.

OBES SURG (2008) 18:1505–1506DOI 10.1007/s11695-008-9525-8

A. Helmy (*) :H. Al Ashgar :A. Benmousa :K. Al KahtaniSection of Gastroenterology, Department of Medicine MBC: 46,King Faisal specialist Hospital & Research Centre,P.O. Box 3354, Riyadh 11211, Saudi Arabiae-mail: ahsalem10@hotmail.com

References

1. Mathus-Vliegen EM, Tytgat GN. Intragastric balloon for treatment-resistant obesity: safety, tolerance, and efficacy of 1-year balloontreatment followed by a 1-year balloon-free follow-up. GastrointestEndosc. 2005;61:19–27.

2. Genco A, Cipriano M, Bacci V, et al. BioEnterics IntragastricBalloon (BIB): a short-term, double-blind, randomised, controlled,crossover study on weight reduction in morbidly obese patients. IntJ Obes. 2006;30:129–33.

3. Butterwegge M, Gethmann U, Ohlenroth G. Ileus in pregnancyinduced by a gastric balloon. Zentralbl Gynakol. 1993;115:238–40.

Fig. 1 Plain X-ray of theabdomin showing the BIB(arrow)

Fig. 2 CT of the abdominshowing the BIB (thick arrow)and the subinvoluted uterus(thin arrow)

Fig. 3 The BIB partially covered with food residue and fungalinfection at gastroscopy

1506 OBES SURG (2008) 18:1505–1506