Protein Shakes: An Unusual Cause of Gastric Phytobezoar in a Health Obsessed Person Jagpal S. Klair, MBBS; Mohit Girotra, MD, FACP; Jonathan A. Dranoff, MD; Farshad Aduli, MD Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences (UAMS) & Central Arkansas Veterans Health Services (CAVHS), Little Rock, AR INTRODUCTION Upon detailed interview of risk factors, he revealed his passion for exercising, intense gym regimen, high intake of protein shakes and other protein supplements over the past few months. Working hypothesis: Protein shakes were probably making stomach contents stay for longer periods of time, decreasing gastric emptying and precipitating bezoar formation. Management: Advised to alter diet by minimizing slow digestible substances like fiber, fruits and vegetables, while avoiding protein shakes. Started on Papain 1-2 tsf/250 ml water PO TID + pineapple juice/coca-cola to assist in dissolving bezoars, with Metoclopramide to assist gastric emptying. Patient expressed strong interest in surgical removal of bezoar, but was appropriately counseled to try conservative measures. Repeat EGD in 1 month revealed significant decrease in the size of gastric phytobezoar making endoscopic removal of residual phytobezoar possible. Patient remained asymptomatic thereafter on clinical follow-ups. Bezoars are retained concretions of undigested foreign material that accumulate and coalesce within the gastrointestinal tract Gastric phytobezoars consist of components of indigestible plant and animal material. Other bezoars: Tricho (hair), Lacto (undigested milk concretions in neonates), Pharmaco (Medications) Usually asymptomatic, but may be brought to attention when become symptomatic with nausea, vomiting, abdominal pain, upper GI bleeding or in severe cases gastric outlet obstruction or perforation. Usual predisposing conditions: diabetes, gastroparesis, hypothyroidism, neurologic disorders (GBS), psychiatric illness, other motility disorders and/or altered gastric anatomy. CASE 35 year-old man with no medical history Gradually progressive abdominal pain and distention with occasional nausea, vomiting, early satiety and 10 lb. weight gain over 3-4 months. Healthy lifestyle, non-smoker, non-alcoholic, no history of illicit drug use and took no prescribed medications. Routine blood-work, thyroid panel, ultrasound and CT abdomen/pelvis were unremarkable. Referred for endoscopy. EGD: Large phytobezoar extending from gastric fundus to antrum. Gastric biopsies were unremarkable for any infiltrative process. DISCUSSION CONCLUSIONS Protein shakes consist of large proportions of protein content that takes longer to digest than carbohydrates, due to which food stays in stomach longer than usual. Effect is more pronounced with casein powder because casein is a very slow-digesting protein. May precipitate undigested food hardening into solid masses. Diagnosis: Plain AXR – filling defect; Barium studies – contrast material coating the bezoar; CT to exclude perforation; EGD Goals of treatment: Remove bezoar (surgically, endoscopically or dissolution therapy with proteolytic papain or cellulase enzymes plus prokinetics) and preventing recurrence. Our novel case intends to make physicians cognizant regarding this rare etiology of phytobezoars in modern day individuals, who often consume protein shakes and powders as health supplements to their exercise regimen, without understanding their possible adverse effects. REFERENCES Pfau P, Ginsberg G. Foreign Bodies and Bezoars. In Feldman: Sleisenger and Fordtran’s Gastrointestinal and Liver Diseases, 7th edition. 2002:395-397. Zhang RL, Yang ZL, Fan BG. Huge gastric disopyrobezoar: a case report and review of literatures. World J Gastroenterol. 2008 Jan 7;14(1):152-4.