Symptomatic bacterial contamination of an intragastric balloon

A 45-year-old woman had an intragastric balloon placed endoscopically for metabolic syndrome and obesity (body mass index = 37.42 kg/m2). She was being maintained on omeprazole daily. Under endoscopic view, the balloon was positioned in the stomach and inflated with 650 mL of 0.9% NaCl mixed with 20 mL of methylene blue solution. After 4 months, the patient had lost 22 kg but began to report intense nausea, vomiting, abdominal distention, and abdominal pain. An abdominal plain film showed a radiolucent and elongated structure in the upper abdomen (A). Endoscopy revealed an enlarged balloon, and the solution inside the balloon was collected during its removal by puncture. Inspection of the balloon after withdrawal showed its surface to be irregular with microbubbles and what appeared to be extensive fungal colonization (B). No samples were taken from the balloon surface, but culture and examination of the solution inside the balloon revealed Klebsiella pneumoniae (a gas-producing bacterium) and Candida spp. The patient was discharged without any symptoms and remained asymptomatic during the next 3 months. Disclosure All authors disclosed no financial relationships relevant to this publication. Commentary Patients with intragastric bezoars lose weight, an observation that prompted Mary and Lloyd Garren to develop the first intragastric balloon to function as an artificial bezoar, ostensibly by inducing a feeling of satiety and thereby helping to curb appetite. In 1985, the U.S. Food and Drug Administration approved the use of a 200-mL air-filled cylindrical, but sharp-edged, plastic bubble, ie, the Garren-Edwards Gastric Bubble, for use in morbidly obese patients, as an adjunct to dietary and behavior modification therapy. Other intragastric balloons have been developed and tried since then and have indeed resulted in weight loss, which sometimes was quite significant, although several randomized, controlled studies failed to show a significant advantage of the balloon over a sham procedure. Reported complications of intragastric balloons have included gastric ulceration, bubble intolerance, and, perhaps most important, spontaneous deflation of the bubble with resultant intestinal obstruction, the risk of which is significantly higher when balloons are left in place longer than 6 months. Here the authors report another adverse effect, namely, abdominal distention and pain, attributed to gas production by Klebsiella. The observation of Klebsiella in the balloon raises many questions: Why was the inner balloon not sterile? What happened to balloon permeability over the time that the balloon resided in the stomach? Was inner colonization a local phenomenon facilitated by the clumps of microorgansims on the external surface of the balloon? One would imagine that were gastric acid to have been normal, there probably would not have been a proliferation of “fungal-appearing” forms nor of bacteria other than Helicobacter pylori. How does the presence of an intragastric balloon affect gastric acid secretion? So many questions. Winnie the Pooh said, “No one can be uncheered with a balloon.” Although this balloon probably led to some cheering at first, it then, I am sure, lead to uncheering as reality set in: obesity is a major health problem that involves lifelong attention to diet, behavior modification, and perhaps the help of a skilled surgeon. I wish this patient good fortune.