Definition: a foreign body resulting from accumulation of ingested material – most commonly found as a hard mass / concentration in the stomach.

Types

Phytobezoar: composed of vegetable matter – MOST COMMON

Trichobezoar: composed of hair

Pharmacobezoar: composed of ingested medications

Other: composed of a variety of other substances (tissue paper, shallac, fungus, styrofoam, cement, etc.)

Pathogenesis

• Ingestion of indigestible material
• Delayed gastric emptying
• Composition / Interaction with gastric material – unripe persimmon fruit contain shibuol (soluble tamin), which forms coagulate when mixed with gastric material

Rapunzel Syndrome: trichobezoar from the stomach to the terminal ileum

Epidemiology: RARE

• Incidence ~0.3% on EGD
• Phytobezoars – male ~40-50 years old
• Trichobezoars – female ~20s; associated with underlying psychiatric disorder

Risk Factors:

• Gastric dysmotility – underlying anatomic abnormality may predispose to formation
  • 70-94% have had gastric surgery
  • 54-80% have undergone vagotomy / pyloroplasty
• Gastroparesis
• Gastric outlet obstruction
• Dehydration
• Medications – insoluble carrying vehicle, high hygroscopy

Clinical Manifestations:

• Abdominal pain
• Nausea/vomiting
• Early satiety
• Anorexia
• Weight loss
• GIB/Obstruction – NOT COMMON

Physical exam: unremarkable in most, occasional abdominal pain and halitosis.  Alopecia in trichobezoars.

Imaging:

• Abdominal radiograph with/without barium
• Abdominal US
• CT scan

Complications:

• GI perforation
• Peritonitis
• Protein-losing enteropathy
• Steatorrhea
• Pancreatitits
• Intussusception

Diagnosis:

• EGD is required to establish the diagnosis of a gastric bezoar AND to obtain samples to determine composition/type

Management: controversial in the absence of studies comparing different modalities

• Chemical dissolution – administration of an agent to degrade the gastric bezoar (non-invasive / inexpensive); potential complication of SO from partially dissolved bezoars ~ 6 weeks later
  • Coca-cola – 3L/12H; low pH, mucolytic effect, ↑ sodium bicarb content, CO2 bubbles (widely available, inexpensive, well-tolerated)
  • Cellulase – dissolves cellulose found in plant fiber / phytobezoars
  • Papain – type of meat tenderizer with many complications
  • Acetylcysteine – low success rates (~50%)
• Endoscopic removal – fragmenting the bezoar with water jet, direct suction (large channel), forceps, snares; allow the fragments to be cleared.
• Adjuvant prokinetics – Metoclopramide typically used in conjunction with endoscopic / chemical therapy because it may decrease the time to dissolution.
• Surgery – reserved for patients that fail chemical AND endoscopic treatment OR those with complications (obstruction/bleeding) OR when composition is not amendable to either other treatment options.