Abstract

Introduction:  
Gastric lactobezoars (GLB) are rare gastrointestinal masses composed of undigested milk and mucus that present with nonspecific symptoms in infants. Due to their rarity, the diagnosis is often missed resulting in poor outcomes. Here, we describe a case of GLB in an infant who was successfully treated with N-acetylcysteine (NAC).

Case Description:  
A 2-month-old female presented for evaluation of forceful, non-bloody, non-bilious emesis after each feed.   
She was born full-term without complications. The early newborn course was complicated by poor weight gain and formula changes in response to diarrhea, gas, irritability. After transition to foster care, she was noted to have abdominal distention and emesis with ongoing poor weight gain and she was hospitalized. Ultrasound was negative for pyloric stenosis but did show an indeterminate mass-like structure medial to the spleen. Her symptoms rapidly improved and she was discharged with a plan for a short-term repeat ultrasound. Three days later, she was noted to have persistent emesis, ongoing weight loss, mottled extremities, and abdominal distension. She was intermittently tachycardic, but otherwise, vitally stable. An upper GI series and ultrasound revealed the diagnosis of GLB and she was re-admitted.   
She was made NPO and treated with NAC irrigation via nasogastric tube (NGT) and fluid resuscitation. On day 2, murky residuals were recovered consistent with curdled milk. Subsequent imaging showed resolution of the GLB but was notable for gastrointestinal reflux and slow gastric emptying. NAC was discontinued and she was started on fortified NGT feeds. However, with recurrent emesis she was transitioned to Alimentum at 20 kcal/oz based on literature suggesting a risk with calorically dense feeds and benefit of extensively hydrolyzed formula. Repeat imaging was without evidence of GLB recurrence and she was discharged in stable condition.

Discussion:  
GLB is a rare diagnosis that requires a high degree of clinical suspicion, experienced radiology review, and prompt recognition to prevent life-threatening complications. NAC appears to be a safe and effective treatment option. In this case, significant social stressors associated with poor weight gain and dehydration were thought to be the main contributing factors to the formation of the GLB. This case underscores the need for meticulous care of children in foster care.