Spontaneous hyperinflation of intragastric balloon: What caused it?

Intragastric balloons (IGBs) are an established, minimally invasive treatment option for obesity. Multiple studies have shown them to be safe and effective in achieving weight loss at 6 months and 1 year. IGBs with newer designs, various filling volumes, and longer indwelling times are currently becoming available to minimize intolerance and improve patient adherence [1]. The overall reported rate of complications with IGBs is very low. However, when a complication does occur, it can be severe and debilitating [2]. In this video, we describe a relatively under-reported complication of IGBs.

A 42-year-old woman underwent endoscopic placement of an IGB for the treatment of obesity (weight 76 kg, body mass index 31 kg/m²). She did not have any co-morbidities. The stomach was normal, and we inflated the IGB (Orbera, Apollo Endosurgery, USA) with 650 mL of normal saline and 1 % methylene blue. We discharged her with proton pump inhibitors and anti-emetic medications.

She tolerated the IGB well. However, at 7 weeks, she presented with severe vomiting, abdominal pain, and distension. Examination revealed a distended left upper abdomen with a palpable IGB ([Fig. 1]). Laboratory analysis showed metabolic alkalosis (pH 7.44, bicarbonate 21.7 mmol/L, potassium 3.7 mmol/L). X-rays demonstrated a large air–fluid level, and massive enlargement of the IGB (~1437 mL) compared with its original volume ([Fig. 2]). Repeat endoscopy showed a hyperinflated IGB causing pyloric obstruction, with no visible signs of microbial colonization ([Fig. 3], [Video 1]). We punctured the balloon and aspirated the mid-stream fluid for microbiological assessment; we then removed the balloon. The specimen culture showed Candida parapsilosis. The symptoms resolved entirely after IGB removal, and no antifungal treatment was administered.

Fig. 1 The patient presented with abdominal pain and distension at 7 weeks after intragastric balloon placement. Examination revealed a visible bulge in the left upper quadrant. The distended balloon was easily palpable.

Fig. 2 Erect and supine X-ray images showed a grossly distended intragastric balloon. A large air–fluid level can be appreciated. Calculation of the volume (4/3 πr³) showed the balloon was approximately twice its original volume.

Fig. 3 Endoscopic view showed a distended balloon with an air–fluid level. The balloon was partially obstructing the pylorus and causing gastric outlet obstruction.

Video 1 Hyperinflated intragastric balloon causing pyloric obstruction.

C. parapsilosis can grow in the presence of high saline concentrations and can produce gas by fermentation, resulting in IGB hyperinflation [3] [4]. The nutritive environment and slow gastric emptying after IGB placement may have promoted the rapid colonization of Candida [5]. Early recognition and IGB removal may prevent serious complications.

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^* These authors contributed equally to this work.

• References

• 1 Choi SJ, Choi HS. Various intragastric balloons under clinical investigation. Clin Endosc 2018; 51: 407-415
• 2 Stavrou G, Tsaousi G, Kotzampassi K. Life-threatening visceral complications after intragastric balloon insertion: Is the device, the patient or the doctor to blame?. Endosc Int Open 2019; 7: E122-E129
• 3 Kotzampassi K, Vasilaki O, Stefanidou C. et al. Candida albicans colonization on an intragastric balloon. Asian J Endosc Surg 2013; 6: 214-216
• 4 Krauke Y, Sychrova H. Four pathogenic Candida species differ in salt tolerance. Curr Microbiol 2010; 6: 335-339
• 5 de Quadros LG, Dos Passos Galvão Neto M, Grecco E. et al. Intragastric balloon hyperinsufflation as a cause of acute obstructive abdomen. ACG Case Rep J 2018; 5: e69