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Bezoar

A bezoar is an indigestible mass composed of fibers and hair which is found in the gastrointestinal system. Consumption of hair, fibers or plastic which do not get digested, eventually form this mass.


Presentation

Gastric bezoars can give rise to various debilitating symptoms. Affected individuals suffer from delayed gastric emptying, nauseas, vomiting, and early feeling of satiety, anorexia, weight loss, dysphagia and abdominal bloating. About 80% of patients with bezoar suffer from epigastric discomfort [6].

Bezoars which develop in the esophageal route, present with signs and symptoms of odynophagia, retrosternal pain and dysphagia.

Candidiasis
  • One older child with acute myeloid leukemia had CB during chemotherapy and one ex-premature developed CB following cerebral candidiasis. All children received systemic antifungal medication; in seven children invasive treatment was added.[ncbi.nlm.nih.gov]
Crying
  • They presented with vomiting, irritable crying, and abdominal distention. Barium gastrointestinal series clearly revealed intraluminal filling defect in the duodenum in two cases and ileum in one.[ncbi.nlm.nih.gov]
Vomiting
  • They usually present with abdominal pain, intestinal obstruction, weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred method of diagnosis.[ncbi.nlm.nih.gov]
  • This is a case of a 3-year-old boy with a sunflower-seed rectal bezoar who presented to our emergency department with fever, abdominal pain, leukocytosis, vomiting, and an examination concerning for appendicitis.[ncbi.nlm.nih.gov]
  • A 52-year-old male patient with psychiatric medical history who presented to the emergency department five times during a period of 5 years due to gastric outlet obstruction manifested mainly by abdominal pain, vomiting and haematemesis after intentionally[ncbi.nlm.nih.gov]
  • They presented with vomiting, irritable crying, and abdominal distention. Barium gastrointestinal series clearly revealed intraluminal filling defect in the duodenum in two cases and ileum in one.[ncbi.nlm.nih.gov]
  • Nausea and vomiting after gastric bypass are common, but some of the underlying causes may be life threatening or, in some cases, unusual.[ncbi.nlm.nih.gov]
Nausea
  • Nausea and vomiting after gastric bypass are common, but some of the underlying causes may be life threatening or, in some cases, unusual.[ncbi.nlm.nih.gov]
  • The ingestion of cling film, which is used for preserving food, may lead to a mechanical obstruction of the gut, especially at the second portion of the duodenal segment, and could manifest with abdominal pain, epigastric distress, nausea, vomiting, and[ncbi.nlm.nih.gov]
  • After 7 days of complete adherence to diet and no purging in hospital, she complained of increased nausea. She vomited up a cylindrical mass that was sent for pathology. A literature search yielded only one report of a bezoar in AN.[ncbi.nlm.nih.gov]
  • She presented with epigastric pain, nausea, and vomiting. Upper gastrointestinal endoscopy, performed at a local hospital, showed 2 gastric bezoars in the stomach, and 1 of them impacted at the pylorus.[ncbi.nlm.nih.gov]
  • Patients may present with abdominal pain, nausea, vomiting, anorexia, weight loss, intestinal bleeding from pressure ulcer necrosis, or intestinal obstruction.[karger.com]
Loss of Appetite
  • They usually present with abdominal pain, intestinal obstruction, weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred method of diagnosis.[ncbi.nlm.nih.gov]
  • Symptoms: Symptoms of bezoars include delayed gastric emptying, early satiety value, loss of appetite, nausea accompanied by vomiting, weight loss, dysphagia, retrosternal pain and odynophagia.[symptoma.com]
  • Bezoars Symptoms Some common bezoars symptoms are: Indigestion Cramps, Bloating, Stomach upset or distress Early fullness and unable to take on more, Nausea or Vomiting Loss of appetite Diarrhea Pain Gastric ulcers Blood in the stool Sometimes fever Abdomen[gastrodigestivesystem.com]
  • In order to investigate the cause of her dysphagia and loss of appetite, she had undergone an upper gastrointestinal endoscopy 3 weeks before this admission.[jmedicalcasereports.biomedcentral.com]
Early Satiety
  • Gastric Bezoar Left: 69 year-old man with diabetes mellitus and end-stage renal disease with gastroparesis (delayed gastric emptying), who presented with nausea, postprandial vomiting and early satiety.[endoatlas.com]
  • But when symptoms do develop, they typically include abdominal pain, nausea, vomiting, early satiety, foul breath, and weight loss. Sometimes, the abdomen feels tender. I checked with Gerard E.[drweil.com]
  • satiety History of trichophagy – eating hair Trichoptysis – hair may be coughed up May be asymptomatic Phytobezoar (55% of all bezoars): Poorly digested vegetable fibers such as Skin and seeds of fruits and vegetables Oranges Persimmons Most common Unripe[learningradiology.com]
  • Symptoms: Symptoms of bezoars include delayed gastric emptying, early satiety value, loss of appetite, nausea accompanied by vomiting, weight loss, dysphagia, retrosternal pain and odynophagia.[symptoma.com]
  • Early satiety and better tolerance to liquid than solid food may represent gastric dilatation, which may be appreciated by succussion splash.[jmedicalcasereports.biomedcentral.com]
Epigastric Pain
  • She presented with epigastric pain, nausea, and vomiting. Upper gastrointestinal endoscopy, performed at a local hospital, showed 2 gastric bezoars in the stomach, and 1 of them impacted at the pylorus.[ncbi.nlm.nih.gov]
  • Case presentation A 62-year-old Asian woman with a history of gastrojejunostomy for peptic ulcer disease was admitted to hospital with epigastric pain, vomiting and dehydration.[jmedicalcasereports.biomedcentral.com]
  • Bezoars mostly originate in the stomach probably related to high fat diet causing non-specific symptoms like epigastric pain, dyspepsia and post-prandial fullness, the stomach is not able to push the hair or other substance out of the lumen because the[bmcsurg.biomedcentral.com]
  • However, as trichobezoars grow in size, they may present with epigastric pain, gastric outlet obstruction, ulceration, GI bleeding, and/or, potentially, perforation. 6 , 10 Phytobezoars usually form more rapidly than trichobezoars.[ncbi.nlm.nih.gov]
Opisthotonus
  • Toad Venom (90 mg/kg) caused opisthotonus, ventricular arrhythmias, and increases in cardiac levels of Ca(2 ), CK and LDH.[ncbi.nlm.nih.gov]
Social Isolation
  • He experienced increasing social isolation and emotional lability over 5 years. Radiological findings confirmed the diagnosis, noting multiple radiopaque foreign bodies. Several types of pica are described based on the substance consumed.[ncbi.nlm.nih.gov]
Emotional Lability
  • He experienced increasing social isolation and emotional lability over 5 years. Radiological findings confirmed the diagnosis, noting multiple radiopaque foreign bodies. Several types of pica are described based on the substance consumed.[ncbi.nlm.nih.gov]

Workup

Physical examination is of little importance in diagnosing bezoars. However, apparently a palpable mass may be detected during physical exam. However, such finding may be an indication of other conditions and therefore more discrete examination needs to be conducted.

Plain radiographs would help in detection of mass in the abdomen. For more distinct analysis, barium swallow X-ray is indicated. In many instances, endoscopy would also be required for determining bezoars in the esophagus or stomach [7]. In addition, CT scan of the abdomen is also indicated for diagnosing bezoars and identifying associated complications [8].

Treatment

  • The primary goal of treatment of bezoars is their removal and designing preventive strategies to prevent recurrence. Surgical removal of bezoars forms the preliminary basis of treatment regime. Other treatment methods consist of endoscopic fragmentation, dissolution of the bezoars with enzymes such as cellulase or proteolytic enzymes, gastric lavage and dietary modifications with inclusion of more fibrous foods. The mode of treatment employed would largely depend on type and location of the bezoar.
  • Majority of the bezoars would require operative removal due to the underlying risks that they carry. Endoscopic methods to remove the bezoars have also achieved considerable amount of success. This mode of treatment is majorly used of trichobezoars. Phytobezoars can be enzymatically removed by dissolving them with various enzymes. Papain, which is a proteolytic enzyme, is also used for removal of phytobezoars.
  • An alternative enzyme therapy involving the use of cellulase for dissolving the phytobezoars has been found to be successful. The cellulase enzyme binds the leucoanthocyanidin-hemicellulose-cellulose bonds, which then dissolves the bezoar [9].
  • The method of gastric lavage which is done using 3 liters of coca cola beverage over a 12 hour period helps in dissolution of phytobezoars [10]. 

Prognosis

The prognosis of the condition is extremely favorable with full recovery. Medications or surgery can help get rid of the bezoar and individuals can also get prompt relief from the debilitating symptoms [5].

Etiology

Consumption of substances containing hair or fizzy materials knowingly or unknowingly favors the development of bezoars. The incidence of bezoars is a common occurrence in animals. In humans, it is thought to occur in children or adults with intellectual disability or in those who are suffering from psychiatric illness [2]. Apart from being a common occurrence in this population, bezoars in adult patients occur due to manipulation during operative procedures such as vagotomy and partial gastrectomy [3].

In addition, there are various other predisposing factors that favor bezoar formation. These include disease conditions such as diabetes mellitus, hypothyroidism, Miltonic dystrophy, Guillain-Barré syndrome, cystic fibrosis and intrahepatic cholestasis.

Epidemiology

The incidence rate of bezoars in humans is low. Mortality rates associated with the condition is about 30%. The fruit persimmon has been linked to occurrence of bezoars in humans. It has been reported that, excessive consumption of persimmon caused an outbreak of intestinal bezoars. About 90% cases of intestinal bezoars occurred due to high consumption of persimmon.

Animals are known to fall easy prey to this condition. In the past era, in the Middle Ages bezoars were considered as valuable possessions and were frequently used for designing jewelry. 

Sex distribution
Age distribution

Pathophysiology

Bezoars are composed of undigested materials and may contain hair, fiber, medications, food or even chewing gum. These materials do not get digested and as a result also do not pass down the small intestine. Bezoars are more commonly found in the stomach, although they can develop anywhere between the esophagus and rectum.
Individuals with past history of gastric surgery or an altered function of gastric motility, wherein there is significant loss of peristaltic motility, are more prone to develop bezoars [4].

Prevention

Individuals who have suffered from a bezoar in the past should be careful about its recurrence in future. Parents should be cautious and keep an eye on children who have habit of putting everything inside their mouth. All indigestible materials should be kept out of reach and they should also cut their children’s hair short, so that they can no longer chew their hair.

Summary

Indigestible materials may get trapped in the gastrointestinal system. As these are not digested, they do not further pass through the small intestine. Bezoars are of 4 types which have been categorized based on their composition: phytobezoars, trichobezoars, lactobezoars and pharmacobezoars. Phytobezoars constitute of vegetable matter and are the most common form; whereas trichobezoars consists of hair and fiber materials. Lactobezoars primarily consist of undigested milk matter and pharmacobezoars are also known as medication bezoars which form due to certain medications [1].

Patient Information

  • Definition: A bezoar is a mass of indigested material that gets accumulated in the gastrointestinal system and give rise to debilitating complications. These comprise of food materials, chewing gum, hair and medications. If these enter the system, they do not get digested and eventually accumulate and form a mass.
  • Cause: Consumption of indigestible materials either knowingly or unknowingly gives rise to formation of bezoars. Individuals suffering from psychiatric illness or those who have undergone surgery are more likely to develop bezoars.
  • Symptoms: Symptoms of bezoars include delayed gastric emptying, early satiety value, loss of appetite, nausea accompanied by vomiting, weight loss, dysphagia, retrosternal pain and odynophagia. Untreated bezoars can pave way for life threatening complications such as ulceration, necrosis and gastrointestinal bleeding.
  • Diagnosis: Physical examination is of little value in diagnosing bezoars. However, a palpable mass during the examination can provide a clue for some underlying problem. In addition, radiographs and barium swallow X-ray can be of considerable help in diagnosing bezoars. CT scan of the abdomen is also indicated.
  • Treatment: Surgery or dissolution by enzymes forms the preliminary basis of treatment regime. Surgical removal of the bezoars is one of the most common methods of treating the condition. Dissolution by enzymes such as cellulase or proteolytic enzymes also helps in treatment of bezoars. Use of coca cola beverage in gastric lavage has also achieved considerable amount of success in treating phytobezoars.

References

Article

  1. Lee J. Bezoars and foreign bodies of the stomach. Gastrointest Endosc Clin N Am 1996; 6:605.
  2. Kamal I, Thompson J, Paquette DM. The hazards of vinyl glove ingestion in the mentally retarded patient with pica: new implications for surgical management. Can J Surg 1999; 42:201.
  3. Brady PG: Gastric phytobezoars consequent to delayed gastric emptying. Gastrointest Endosc 1978, 24:159-161.
  4. Kadian RS, Rose JF, Mann NS. Gastric bezoars--spontaneous resolution. Am J Gastroenterol 1978; 70:79.
  5. Calabuig R, Navarro S, Carrio I, Artigas V, Mones J, Puig LaCalle J: Gastric emptying and bezoars. Am J Surg1989, 157:287-290.
  6. Robles R, Parrilla P, Escamilla C, Lujan JA, Torralba JA, Liron R, Moreno A: Gastrointestinal bezoars. Br J Surg1994, 81:1000-1001.
  7. Wang YG, Seitz U, Li ZL, et al. Endoscopic management of huge bezoars. Endoscopy 1998; 30:371.
  8. Newman B, Girdany BR. Gastric trichobezoars--sonographic and computed tomographic appearance. Pediatr Radiol 1990; 20:526.
  9. Rider JA, Foresti-Lorente RF, Garrido J, et al. Gastric bezoars: treatment and prevention. Am J Gastroenterol 1984; 79:357.
  10. Ladas SD, Kamberoglou D, Karamanolis G, et al. Systematic review: Coca-Cola can effectively dissolve gastric phytobezoars as a first-line treatment. Aliment Pharmacol Ther 2013; 37:169.

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Last updated: 2017-08-09 18:19