A248 PHYTOBEZOARS - A POTENTIAL CONCERN FOR PARKINSON’S PATIENTS ON DUODOPA THERAPY

Parkinson’s disease (PD) is a common neurodegenerative disease(1). The majority of PD patients progress with worsening motor fluctuations and dyskinesias refractory to conventional therapy of levodopa/carbidopa (L/C)(2). Thus, in refractory cases, delivery of a continuous infusion of a L/C gel, known as Duodopa(3) via a PEG/PEJ can be offered. This option, of proven efficacy, has the benefit of bypassing the stomach altogether (commonly paretic due to PD) and attaining a steadier level of drug(1–4). We present a case of a phytobezoar attached to a Duodopa PEJ causing obstruction and ulceration and review the litterature. Case This case involves a 75-year-old female diagnosed with PD in 1995. The progression of severe dyskinesia and motor fluctuations despite optimization of oral L/C deemed the patient a good candidate for the PEG/PEJ Duodopa program. The apparatus was successfully installed in January of 2016. A follow up in gatroenetrology on 10/03/2018 was arraged due to a 6 month history of episodic abdominal pain (AP) and decreased oral intake, followed by a 15% weight loss. Her symptoms culminated in severe AP and vomiting for the last three weeks prior to being seen. A gastroscopy was performed, revealing that the PEJ tube was eroding into the pyloric channel with continuous extension of the deep erosive ulceration well into the duodenal bulb, flexure, and third stage. There was cavernous dilation of the 2nd and 3rd stage of the duodenal lumen with a 2 cm phytobezoar (PB) attached to the end of the PEJ. This created an anchor-like phenomenon with resulting tension on the PEJ and lateral erosion into any surrounding soft tissue, as well as a partial duodenal obstruction. The apparatus was severed and the PEJ tube, along with the phytobezoar and internal bumper, were snared and removed. Initiation of Duodopa treatment carries certain risks and complications. The adverse events can be related to the gastrostomy insertion, the infusion system or the drug itself(3). We performed a literature review looking specifically at mechanical complications related to PB formation. Two mechanical obstructions were described from PBs, one managed endoscopically while the other necessitated surgery(7). An incidentally discovered large non-complicating gastric PB was managed with Coca-Cola consumption(8). One case reports the formation of a large duodenal ulcer from a PB lodged at the PEJ tip which was managed by device removal(9). An additional case described jejunitis caused by a PB(10). Another case described multiple fistula formations from a PB necessitating three surgeries – this case had a fatal outcome(11). PB formation at the tip of the PEJ tube appears to be a real complication of the Duodopa system. It is imperative that physicians caring for these patients are aware of this potential complication and act on concerning symptoms promptly. None

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