Definition: a foreign body resulting from accumulation of ingested material – most commonly found as a hard mass / concentration in the stomach.
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.)
- 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
- Incidence ~0.3% on EGD
- Phytobezoars – male ~40-50 years old
- Trichobezoars – female ~20s; associated with underlying psychiatric disorder
- Gastric dysmotility – underlying anatomic abnormality may predispose to formation
- 70-94% have had gastric surgery
- 54-80% have undergone vagotomy / pyloroplasty
- Gastric outlet obstruction
- Medications – insoluble carrying vehicle, high hygroscopy
- Abdominal pain
- Early satiety
- Weight loss
- GIB/Obstruction – NOT COMMON
Physical exam: unremarkable in most, occasional abdominal pain and halitosis. Alopecia in trichobezoars.
- Abdominal radiograph with/without barium
- Abdominal US
- CT scan
- GI perforation
- Protein-losing enteropathy
- 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.