Clinical Analysis

• Sensation of a solid/hard mass in the epigastric region after dinner
• Symptoms persisting overnight (no spontaneous resolution)
• Hunger present, but pain on eating or drinking
• No nausea, no vomiting
• Episode of near-syncope/vertigo (likely vasovagal or hypotensive episode related to the obstruction)

Most Likely Diagnosis: Gastric Bezoar (possibly a Phytobezoar)

What is a Bezoar?

"Many patients with bezoars are asymptomatic, but epigastric pain, early satiety, nausea, and vomiting are common manifestations of a bezoar. Bloating, malaise, and weight loss may also be reported... On physical examination, potential findings include abdominal tenderness, a palpable mass, and a succussion splash." (Yamada's Gastroenterology, block11)

• Sensation of a solid, persistent mass in epigastrium - classic
• Pain on eating or drinking - the food/drink meets the bezoar and cannot pass easily
• No nausea/vomiting - not always present, especially early stages
• Overnight persistence - bezoars do not spontaneously resolve

Second Differential: Functional Dyspepsia - Postprandial Distress Syndrome (PDS)

• Postprandial fullness/discomfort after meals
• Early satiety
• Epigastric burning or pain
• Hunger present between meals, but pain worsened by eating

Third Differential: Acute Biliary Colic / Cholelithiasis

• Young women (especially lactating/postpartum) are at significantly higher risk for gallstone formation due to pregnancy-related changes in bile composition and progesterone-mediated gallbladder stasis
• Biliary pain is typically postprandial, epigastric or RUQ, and can feel like a "pressing" sensation
• Usually lasts 30 minutes to several hours, then resolves - but if a stone is lodged in the cystic or common bile duct, pain can persist overnight
• The vertigo-like episode + low blood pressure fits a vasovagal response triggered by severe visceral pain

"Biliary pain is a syndrome of RUQ or epigastric pain, usually postprandial, caused by transient obstruction of the cystic duct by a gallstone; it is self-limited, generally lasting..." (block2, line 2659)

Fourth Differential: Peptic Ulcer Disease (PUD)

• Epigastric pain that is worsened by eating (gastric ulcer pattern) or relieved by eating (duodenal ulcer)
• Hunger pain is characteristic of duodenal ulcer (pain improves transiently with eating then returns)
• No nausea/vomiting does not exclude it
• Low BP + vertigo could represent a significant bleed if there were a gastric/duodenal ulcer, but with no melena or hematemesis mentioned, less likely to be complicated

Summary Table

Recommended Workup

1. Upper GI Endoscopy (OGD) - first-line investigation; will confirm bezoar, ulcer, or mucosal changes. Per Yamada's: "endoscopy remains the test of choice" for bezoar diagnosis.
2. Abdominal Ultrasound - to rule out gallstones, bile duct dilatation
3. Complete Blood Count + LFTs + Amylase/Lipase - baseline
4. Standing BP measurement - she has known hypotension; the vasovagal/vertigo episode should be documented

Special Note: Lactating Mother

• Reduced GI motility (prolactin effects)
• Higher risk of gallstone formation (hormonal changes)
• Nutritional deficiencies that may predispose to gastroparesis

Treatment Plan

Treating Each Diagnosis in Order of Priority

1. Gastric Bezoar (Most Likely - Primary Diagnosis)

Step 1 - Initial Stabilization

• NPO (nothing by mouth) or clear liquid diet only - reduces further accumulation
• IV fluids to correct hypotension and hydration
• Monitor blood pressure closely (she has baseline low BP)

Step 2 - Chemical/Enzyme Dissolution (First-line for Phytobezoars)

Per Yamada's Textbook of Gastroenterology: "Several case series have reported significant benefit from Coca-Cola lysis, with a nearly 50% complete resolution. The average amount consumed was 3-4 L, typically administered via nasogastric tube over 12 hours."

Step 3 - Prokinetic Agents (Medical Therapy)

• Metoclopramide 40 mg IV over 24 hours (acute setting) - also prevents recurrence
• Erythromycin (short course) - motilin receptor agonist, promotes gastric emptying
• Domperidone - fewer CNS side effects than metoclopramide; useful for longer-term use

Important for lactating mother: Metoclopramide is compatible with breastfeeding and actually increases prolactin/milk supply as a side effect. Domperidone is also generally considered safe in lactation.

Step 4 - Endoscopic Therapy (If chemical dissolution fails)

• Mechanical fragmentation with forceps, snares, or baskets - breaks bezoar into small pieces that pass through the pylorus
• Large-bore orogastric lavage after fragmentation - aspiration of fragments
• Water Pik lavage through endoscope channel - pulsatile water fragmentation
• Electrohydraulic or laser lithotripsy (Nd:YAG laser) - for hard/refractory bezoars

Per Yamada's Gastroenterology: "Endoscopic therapy aimed at resolution is warranted for symptomatic bezoars... Many bezoars can be mechanically disrupted into small pieces with forceps such that the pieces are retrieved by suction or allowed to pass through the pylorus."

Step 5 - Surgery (Rarely required)

• Gastric or small bowel obstruction unresolved by endoscopy
• Perforation
• Uncontrollable hemorrhage
• Trichobezoars (hair bezoars) - resist standard management and more often require surgery

2. Biliary Colic (Second Differential - Rule Out Urgently)

• Abdominal ultrasound to confirm gallstones
• Pain relief: Diclofenac (NSAID) is first-line for biliary colic analgesia - reduces ductal spasm and inflammation
• Antispasmodics: Hyoscine butylbromide (Buscopan) - relaxes biliary smooth muscle
• IV fluid support given her hypotension

• Laparoscopic cholecystectomy - elective, ideally after 6 weeks postpartum period resolves and breastfeeding is stable
• Ursodeoxycholic acid - for patients unfit for surgery (dissolves cholesterol stones), though slow (months)

Lactation note: NSAIDs like ibuprofen/diclofenac are compatible with breastfeeding. Opioids like morphine or pethidine should be used with caution and only for severe acute pain under supervision.

3. Functional Dyspepsia / Peptic Ulcer Disease (Concurrent Treatment)

• Proton Pump Inhibitor (PPI): Omeprazole 20 mg or Pantoprazole 40 mg once daily
  • Safe in lactation (minimal transfer into breast milk)
• H. pylori testing and eradication if confirmed:
  • Triple therapy: PPI + Amoxicillin + Clarithromycin x 14 days
  • Clarithromycin is generally considered safe in breastfeeding
• Antacids: Magnesium/aluminum hydroxide (Maalox, Gaviscon) - safe in lactation, for immediate symptom relief
• Dietary advice: Small, frequent meals; avoid spicy, fatty, acidic foods; avoid eating quickly

Dietary & Lifestyle Advice (All Conditions)

• Eat smaller, more frequent meals rather than large dinners
• Chew food thoroughly into small pieces before swallowing
• Avoid foods that form bezoars: persimmons, raw fibrous fruits, stringy vegetables, coconut, skins of fruits
• Sit upright for 30-60 minutes after eating - aids gastric emptying
• Treat hypotension: adequate fluid intake, small frequent meals, avoid standing suddenly after meals (this also addresses the vertigo episodes)
• Maintain adequate nutrition for lactation - do not restrict diet excessively

Quick Summary

Acute management:
├── IV fluids + BP monitoring (hypotension)
├── NPO or liquid diet
├── Attempt Coca-Cola/cellulase/acetylcysteine dissolution
├── Metoclopramide IV (prokinetic + antiemetic)
└── Abdominal ultrasound (rule out gallstones)

Next step (if no resolution in 24-48 hrs):
└── Upper GI Endoscopy → Fragmentation/extraction

Discharge medications:
├── PPI (omeprazole/pantoprazole)
├── Prokinetic (metoclopramide or domperidone)
└── Antacid as needed

Follow-up:
├── H. pylori test result
├── Dietary counseling
└── Elective cholecystectomy if gallstones confirmed