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Bezoars

by Michael C. DiMarino, MD

A bezoar is a tightly packed collection of partially digested or undigested material that is unable to exit the stomach. It often occurs in patients with abnormal gastric emptying, especially those that have diabetic gastroparesis, as well as after gastric surgery. Many bezoars are asymptomatic, but some cause symptoms of gastric outlet obstruction. Some can be dissolved enzymatically, others removed endoscopically, and some require surgery.

Partially digested agglomerations of vegetable matter are called phytobezoars; agglomerations of hair are called trichobezoars. Pharmacobezoars are concretions of medication (particularly common with sucralfate and aluminum hydroxide gel). Many other substances have been found in bezoars.

Etiology

Trichobezoars, which can weigh several kg, most commonly occur in patients with psychiatric disturbances who chew and swallow their own hair. Phytobezoars often occur in patients who have undergone a Billroth I or II partial gastrectomy, especially when accompanied by vagotomy. Hypochlorhydria, diminished antral motility, and incomplete mastication are the main predisposing factors; these factors are more common among the elderly, who are thus at higher risk of bezoar formation. Others include diabetic gastroparesis and gastroplasty for morbid obesity. Consumption of persimmons (a fruit containing the tannin shibuol, which polymerizes in the stomach) has been known to cause bezoars that require surgery in > 90% of cases. Persimmon bezoars often occur in epidemics in regions where the fruit is grown.

Symptoms and Signs

Most bezoars cause no symptoms, although postprandial fullness, nausea and vomiting, pain, and GI bleeding may occur.

Diagnosis

  • Endoscopy

Bezoars are detectable as a mass lesion on most tests (eg, x-ray, ultrasound, CT) that may be done to evaluate upper GI symptoms. They may be mistaken for tumors; upper endoscopy is usually done. On endoscopy, bezoars have an unmistakable irregular surface and may range in color from yellow-green to gray-black. An endoscopic biopsy that yields hair or plant material is diagnostic.

Treatment

  • Observation

  • Sometimes manual removal via endoscopy

  • Sometimes enzymatic therapy

If initial diagnosis is made by endoscopy, removal can be attempted at that time. Fragmentation with forceps, wire snare, jet spray, or even laser may break up bezoars, allowing them to pass or be extracted.

If endoscopy was not initially done, treatment is based on symptoms. Asymptomatic patients that have a bezoar discovered incidentally during testing for other reasons do not necessarily require intervention. In some cases, a trial of enzymatic therapy can be attempted. Enzymes include papain (10,000 U with each meal), meat tenderizer (5 mL [1 tsp] in 8 oz of clear liquid before each meal), or cellulase (10 g dissolved in 1 L water, consumed over 24 h for 2 to 3 days). If enzymatic therapy is unsuccessful, or if patients are symptomatic, endoscopic removal may be tried. Rocklike concretions and trichobezoars usually require laparotomy.

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