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Bezoars and Foreign Bodies of the Digestive Tract

by Michael C. DiMarino, MD

Bezoars are tightly packed collections of partially digested or undigested material stuck in the stomach or other parts of the digestive tract. Foreign bodies are small ingested objects that can also get stuck in the digestive tract and sometimes perforate (pierce) it.

  • Masses of undigestible materials can get stuck in various parts of the digestive tract.

  • Most bezoars and foreign bodies cause no symptoms.

  • The diagnosis is based on x-rays and sometimes on a visual examination of the digestive tract using endoscopy.

  • Most bezoars and foreign bodies pass without treatment, but some need to be broken down manually or with swallowed agents or removed surgically.

The stomach is a common collection site for hardened, partially digested, or undigested masses of food or other materials (bezoars) or for foreign objects (bodies). Reasons include the curved shape of the stomach and the narrow opening (pyloric sphincter) that the stomach's contents must pass through to enter the first segment of the small intestine (duodenum). Bezoars or foreign bodies larger than ¾ of an inch (about 2 centimeters) in diameter are rarely able to pass out of the stomach.

Bezoars may consist of partially digested hair (called trichobezoars), fiber from fruits (particularly persimmons) or vegetables (called phytobezoars), and even hardened blocks of drugs (such as antacids—called pharmacobezoars), which accumulate most often in the stomach but sometimes elsewhere in the digestive tract. These hairballs or foodballs cannot pass through narrow openings or spaces and thus get stuck in the digestive tract.

Foreign bodies are sometimes swallowed by children and even adults, especially intoxicated adults. If these undigestible objects are small, they pass through the digestive system until they are excreted with stool. However, larger objects or sharp ones, such as fish bones, may get stuck in the esophagus or stomach or, less often, in other parts of the digestive tract (see Foreign Objects in the Rectum). Sometimes foreign bodies are swallowed purposely, as when smugglers swallow balloons filled with illegal drugs to get through customs.

Foreign bodies may be inserted in the rectum intentionally (such as during sexual play) but may become stuck unintentionally.

Food or other materials can collect in anyone but do so more often under certain circumstances. People who have a low level of hydrochloric acid in their stomach, people whose stomach does not move food appropriately, people who wear dentures, and people who chew their food incompletely are at risk of bezoars and foreign bodies. These risks are more common among older people. People who have undergone surgery to their digestive tract, particularly if they have had part of their stomach or intestines removed to treat obesity, are particularly prone to bezoars and foreign bodies becoming stuck. People with diabetes sometimes develop a condition in which the stomach does not empty properly (called diabetic gastroparesis), resulting in problematic collections of food.

Symptoms

Most bezoars and foreign bodies do not completely block the digestive tract and thus cause no symptoms. However, people may feel very full after eating a normal-sized meal and may have nausea, vomiting, and pain.

A small blunt object that is swallowed may cause the sensation of something being stuck in the esophagus. This feeling may persist for a short time even after the object has passed into the stomach. A small sharp object that is swallowed may become lodged in the esophagus and cause pain, even though the person is able to swallow normally. When the esophagus is completely blocked, the person is unable to swallow anything, even saliva, and drools and spits constantly. The person may try to vomit, but nothing comes up. If a sharp object pierces the esophagus, consequences may be serious. People who have swallowed button batteries, which eat away at the lining of the esophagus, may have internal burns.

Sometimes bezoars or foreign bodies lead to blood in the stool. If they are partially or completely obstructing the stomach, the small intestine, or, rarely, the large intestine, they cause cramps, bloating, loss of appetite, vomiting, and sometimes fever. If a sharp object has pierced the stomach or intestines, stool spills into the area around the intestines, causing severe abdominal pain, fever, fainting, and sometimes shock. Such a leakage is a medical emergency because it can cause peritonitis (see Intestinal Obstruction). If a person has swallowed a drug-filled balloon, the balloon may rupture, which can then lead to an overdose of the drug.

Diagnosis

Often, an obstructing object can be seen on x-rays of the abdomen and sometimes of the chest. Usually, endoscopy (a visual examination of the digestive tract using a flexible tube called an endoscope—see Endoscopy) is done to determine the nature of the obstructing object and to exclude a tumor as the cause. During the endoscopy, doctors may remove a piece of a bezoar and examine it under a microscope (called a biopsy) to look for hair or plant material. Computed tomography (CT) and ultrasonography can also be done to identify the problem.

Foreign bodies that are stuck in the rectum can be felt during a digital examination, in which a doctor inserts a gloved finger in the person's rectum.

Doctors may use a hand-held metal detector to detect metallic foreign bodies (such as coins and batteries). However, these metallic objects are usually detected with x-rays.

Treatment

Most bezoars and foreign bodies require no treatment. Even a small coin is likely to pass without a problem. A doctor advises the person to check the stool to see when the object is excreted. Sometimes a doctor recommends that the person consume a liquid diet to help excrete the object. Some objects, such as toothpicks, remain in the gastrointestinal tract for many years.

Bezoars

To help break down a bezoar, a doctor may prescribe a regimen of enzymes such as papain and meat tenderizer, which are taken with meals, or cellulase, which is dissolved in a liquid and taken by mouth for 2 to 3 days.

Sometimes doctors use forceps, a laser, or other instruments to break up bezoars so that they can pass through or be removed more easily. Bezoars that are hard as rocks usually need to be removed surgically.


Foreign bodies

When a doctor suspects that a blunt foreign body is stuck in the esophagus, the drug glucagon may be given by vein (intravenously) or the drug lorazepam may be given by vein to relax the esophagus and allow the object to pass through the digestive tract.

Doctors can remove some objects that are stuck in the esophagus with forceps or a basket passed through an endoscope.

Because sharp objects may pierce the wall of the esophagus, they must be removed, either by endoscopy or surgery. Batteries are also removed from the esophagus or stomach because they can cause internal burns. When an object suspected of being a drug-filled balloon is detected, it is removed to prevent the drug overdose that can occur if such a balloon ruptures.

Foreign bodies in the rectum may need to be removed manually. After the person's anus has been numbed with injections of a local anesthetic and held open with a special instrument, doctors are able to use forceps to grasp and remove the object. This procedure often also requires general anesthesia or heavy sedation.


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