AM Report 4/10/17 Gastric Bezoar

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

phytobezoar

Trichobezoar: composed of hair

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Pharmacobezoar: composed of ingested medications

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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

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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 prokineticsMetoclopramide 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.

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