Failure of Computed Tomography (CT) in Detecting an Aspirin Pharmacobezoar: A Case Report

Patient: Female, 64-year-old Final Diagnosis: Salicylate overdose with bezoar • salicylate toxicity Symptoms: Altered mental state • metabolic acidosis • renal failure • respiratory alkalosis • respiratory failure • salicylate toxicity Medication: — Clinical Procedure: CT abdomen and pelvis • hemodialysis • whole bowel irrigation Specialty: Critical Care Medicine • Gastroenterology and Hepatology • Toxicology OBJECTIVE: Unusual clinical course BACKGROUND: Prior studies suggest CT can identify bezoars under certain circumstances. Endoscopy provides diagnostic and therapeutic benefit in the setting of suspected aspirin bezoar. Does the absence of findings on CT scan exclude the presence of an aspirin bezoar? CASE REPORT: A 64-year-old woman called the police and stated she ingested a bottle of aspirin to harm herself. Upon arrival to the Emergency Department, she was tachypneic with a GCS of 15. Initial laboratory results were: salicylate level of 1143 mcg/mL, respiratory alkalosis, bicarbonate of 9 meq/L, anion gap of 23, and normal renal function. Initial therapeutic intervention included infusions of glucose and bicarbonate, multiple doses of activated charcoal, intubation, and emergent hemodialysis. After hemodialysis, the salicylate level rebounded, and a Gastroenterology (GI) consultation was requested to rule out bezoar. On day 2, GI requested an abdominal CT scan with Gastrografin in place of endoscopy due to hemodynamic instability. A CT scan was negative for bezoar. After multiple hemodialysis sessions and whole-bowel irrigation with rebounding salicylate levels, GI was consulted again for reevaluation for endoscopy. On day 5, an endoscopy discovered a concretion containing pill fragments. Another endoscopy performed on day 7 removed further fragments. Salicylate levels began to consistently decline. Unfortunately, the patient’s neurologic status did not improve, and on day 11 she was switched to palliative care and died. CONCLUSIONS: Endoscopy with direct visualization is diagnostic and therapeutic in the setting of a possible bezoar. The absence of pharmacobezoar on imaging should not delay endoscopy in a clinical setting suggesting bezoar.