Answers to Epilogue questions
=============================

* David Sinton
* Pamela Dawson
* Thillagavathie Pillay

*   Neonatology
*   Twins
*   Gastroenterology
*   Paediatric Surgery

## Answers

*From questions on page 94.*

1.  The diagnosis is gastric lactobezoars without small bowel obstruction. A lactobezoar is a compacted mass of undigested milk concretions and mucous secretions within the gastrointestinal tract. The majority form in the stomach but may be found in upper and lower intestines.1

Lactobezoars are well recognised but rarely reported. A review article from 2012 reported 96 cases published since 1959.1 The peak incidence in neonates was on days 4–10 of life.2

The diagnosis is challenging as the presentation is often non-specific.

In as many as 60% of reports, features mimic those of feed intolerance;1 it is possible that transient lactobezoars are inadvertently but appropriately treated as such.

*   2. Endogenous factors include: neonatal period; prematurity; low birth weight (<2500 g); dehydration; and immature gastrointestinal function (altered gastric secretions and delayed emptying).

Exogenous factors include: medications which alter gastric secretion and motility (eg, Gaviscon, H2 receptor antagonists, breast milk fortifier (BMF), prokinetics); formula composition (hypercaloric, casein based or medium chain trigyceride, over-concentration of milk powder); and feeding modalities including early enteral feeding.1–3

In this case, the combination of Gaviscon, BMF, phosphate supplements and erythromycin possibly compounded an underlying susceptibility to bezoar formation. 

*   3. The investigation of choice is ultrasound, showing highly echoic intrabezoaric air trapping. This requires an experienced operator, making it less viable in many centres. Plain films often show the bezoar clearly, as is demonstrated in this case. The second twin's plain film demonstrates the NGT curled into the bezoar, explaining the difficulty with prefeed aspiration. Contrast studies can also be useful.1

Management is largely conservative; nil by mouth, intravenous fluids or TPN and gastric lavage.1 ,4 Gastric washouts revealed thick milky concretions in both twins. This mode of treatment was successful in 85% of the cases described.1 Other management options include gastroscopic disintegration of the bezoar1 ,4 and N-acetyl cysteine gastric washouts.1 ,5

If conservative management is unsuccessful after 72 h, then surgical intervention is indicated. Few cases of bowel obstruction associated with lactobezoars are reported but gastric perforation is a well-recognised complication,2 and surgery is indicated in pneumoperitoneum and acute gastrointestinal obstruction.1 ,4 It is hypothesised that lactobezoars may lead to necrotising enterocolitis.2

## Patient outcome

The twins received 6-hourly washouts for 48 h, nil by mouth and TPN for 4 days. On restarting enteral feeds without additives, they made uneventful recoveries and were discharged by day 58.

## Footnotes

*   Contributors DS and PD drafted the manuscript and collected and analysed data from the reviewed literature. TP provided insights into the pathophysiological mechanisms of lactobezoar formation. DS revised the manuscript and corrected for submission criteria. All authors read and approved the final manuscript.

*   Competing interests None.

*   Patient consent Obtained.

*   Provenance and peer review Not commissioned; externally peer reviewed.

## References

1.  Heinz-Erian P, Gassner I, Klein-Franke A, et al. Gastric lactobezoar—a rare disorder? Orphanet J Rare Dis 2102;7:3.
    
    

2.  Jain A, Godambe SV, Clarke S, et al. Unusually late presentation of lactobezoar leading to necrotising enterocolitis in an extremely low birthweight infant. BMJ Case Rep 2009;3:1708.
    
    

3.  Sorbie AL, Symon DNK, Stockdale EJN. Gaviscon bezoars. Arch Dis Child 1984;59:905–6.
    
    [FREE Full Text](http://ep.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6MzoiUERGIjtzOjExOiJqb3VybmFsQ29kZSI7czoxMjoiYXJjaGRpc2NoaWxkIjtzOjU6InJlc2lkIjtzOjg6IjU5LzkvOTA1IjtzOjQ6ImF0b20iO3M6MjI6Ii9lZHByYWN0Lzk5LzMvMTIwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Vallabhaneni P, Mansour M, Hutton K, et al. Lactobezoar—not so bizarre! Arch Dis Fetal Neonatal Ed 2010;10:1136.
    
    

5.  Bajorek S, Basaldua R, McGoogan K, et al. Neonatal Gastric Lactobezoar: management with N-Acetylcysteine. Case Reports Paediatr 2012;10:1155–8.