P0571 - Beyond the Usual Diet: A Challenging Case of Xylophagia Resulting in Intestinal Obstruction from Xylobezoar

Yash R. Shah, MD¹, Parikshit Narsapuram, MD¹, Samhitha Bitla, MD¹, Geetha Krishnamoorthy, MD¹, Ramy Mansour, DO^2
1Trinity Health Oakland/Wayne State University, Pontiac, MI; ²Trinity Health Oakland, Pontiac, MI

Introduction: Xylobezoar, a rare condition resulting from xylophagia, is characterized by varying degrees of intestinal obstruction due to entrapment of undigested paper in the gastrointestinal tract. We present an endoscopically challenging case of pancolonic obstruction due to toilet paper accumulation in a patient with pica secondary to iron deficiency anemia.

Case Description/Methods: A 61-year-old female with IDA presented with sharp crampy left lower quadrant abdominal pain and constipation for 2 days. Mild abdominal distension and tenderness in the LLQ were noted on physical exam. Vitals were stable on presentation. Labs revealed findings presented in Table 1. CT abdomen pelvis w/ contrast showed sigmoid colitis with moderate to severe colonic fecal loading. She admitted to consuming half a roll of toilet paper for 3 months and was diagnosed with xylophagia. Gastroenterology was consulted; she received full miralax bowel preparation with two soapsuds enema, and underwent EGD and colonoscopy. She had 8/10 generalized abdominal pain prior to the procedure. She was preemptively intubated in anticipation of surgery. EGD showed mild gastritis, while colonoscopy revealed a significant amount of toilet paper in the colon (Figure 1). A xylobezoar was disintegrated and a large amount of toilet paper was removed with sterile water lavage. The scope was not advanced beyond the hepatic flexure due to extensive amount of foreign body. The exam was ultimately aborted due to worsening abdominal distention and respiratory decompensation. A nasogastric tube was placed, and abdominal x-ray showed large pneumoperitoneum under the right hemidiaphragm suggestive of perforation. Surgery was consulted, and an extensive amount of toilet paper was removed during emergent subtotal colectomy with ileostomy, complicated by severe hemorrhage. Unfortunately, the patient coded and succumbed to death.

Discussion: The patient had severe IDA preceding the onset of pica, and low levels of serum iron/ferritin have been associated with pica in multiple population-based studies. While there are no specific guidelines for the management of xylobezoar, various approaches like dissolution with chemicals like cellulase, papain, and acetylcysteine, endoscopic retrieval, or surgery have been attempted. One study has reported the successful treatment of xylobezoar with nasogastric infusion of Coca-Cola®. In conclusion, our case report highlights the need for increased awareness, early intervention, and multi-disciplinary approach in such cases.




Disclosures:


Yash R. Shah, MD¹, Parikshit Narsapuram, MD¹, Samhitha Bitla, MD¹, Geetha Krishnamoorthy, MD¹, Ramy Mansour, DO². P0571 - Beyond the Usual Diet: A Challenging Case of Xylophagia Resulting in Intestinal Obstruction from Xylobezoar, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.