The term bezoar comes from the Persian word badzehr , which refers to the material found in sacrificed animals such as goats. In ancient times, this material was thought to have magical or medicinal powers and was used as an antidote to poisons from snake bites, infections, diverse diseases, and even as a means of combating aging. The Indian physician Charak reported the presence of bezoars in his work in the second and third centuries bc . Baudamant was the first to describe bezoars in the Western world, in an autopsy performed in 1779. Matas performed the first extensive review in 1915; subsequently Debakey and Oschner published their landmark review in 1938. Schonbon first published a description of the surgical removal of bezoars in the 19th century. Thus, once considered a charm, bezoars are now recognized as a potentially serious medical problem. Knowledge of the various types of bezoar as well as predisposing conditions will assist with both treatment and prevention.
Definitions
Bezoars are aggregates or concretions of retained, undigested material found anywhere along the gastrointestinal tract, although they are most commonly found in the stomach. They are classified based on composition. Plant fiber, hair, and medication bezoars have all been well described. A pseudobezoar is an intentionally ingested indigestible foreign object of the gastrointestinal tract.
Epidemiology
The overall incidence of medically relevant bezoars is not known; however, case studies have informed on the occurrence of specific types and predisposing factors ( Table 29-1 ). Case reports of bezoars secondary to gastric surgery are increasing, even in children. This is expected to continue with the increasing frequency of adolescents undergoing Roux-en-Y gastric bypass for obesity. Other operations thought to predispose to bezoar formation include fundoplication, pyloroplasty, and vagotomy for peptic ulcer disease.
| Factor | Prevalence in Patients (%) |
|---|---|
| Poor mastication | 80 |
| Gastric surgery with vagotomy | 56 |
| Gastroparesis | 20 |
| Histamine-2(H2) receptor antagonists | 12 |
| Diabetes mellitus | 6 |
| Excessive intake of fiber | 44 |
Classification and Pathogenesis
Phytobezoars
Phytobezoars are the most frequently observed type and account for approximately 40% of the total number of reported bezoars. They are composed of indigestible plant fibers, most commonly from pulpy fruits, orange pits, seeds, roots, or leaves. Phytobezoars are usually found in the stomach (78%), although up to 17% may occur in the small intestine. Sunflower seed concretions have been described in the colons of children. Phytobezoars are not restricted to foodstuffs; a case of a “cotton” bezoar was reported in a heroin addict who swallowed the cotton ball used to filter a water-methadone pill preparation for intravenous infusion.
Diospyrobezoars (Persimmon Bezoars)
Although made of plant matter, persimmon bezoars represent a class by themselves and account for up to 29% of all bezoars in some series. Persimmon bezoars are named for a Native American tree also present in Iran and the Middle East, Diospyros virginiana . Its fruit, a berry, contains a material called shibuol or phobatanin. This substance is present in the unripened fruit and only under the skin of the ripe fruit.
Trichobezoars
Trichobezoars occur predominantly in females younger than the age of 20 (up to 90%), and often in children. They have been described in children as young as 1 year of age. Trichobezoars consist of an aggregation of hair and foodstuff and are black, regardless of the patient’s hair color, due to the denaturing of hair protein by gastric acid ( Figure 29-1 ). The hair is usually the patient’s own, although hair from animals, carpet, or toys is occasionally recovered. Trichobezoars are a site for intense food putrefaction and can generate a very foul-smelling odor resulting in halitosis. The act of hair swallowing is thought to be akin to pica or nail biting. Trichobezoars are associated with trichotillomania, the impulsive, unintentional act of hair pulling, although only about 6% of those with trichotillomania will develop trichobezoars In fact, only about 9% of patients with trichobezoars have proven psychiatric problems.
Trichobezoars usually are present in the stomach but may have very long tails. These tails can invade the esophagus proximally and extend distally into the small intestine. Rapunzel syndrome occurs with involvement of the stomach and entire length of the small intestine. Trichobezoars may weigh more than 6 pounds.
Lactobezoars
Lactobezoars are gastric masses composed of milk protein. They occur primarily in premature, low-birth-weight infants. Although the exact cause remains unclear, formation is thought to be related to formula composition, protein flocculation, thickening agents, immature gastric motility, and rapidity of feeding. Most reported cases have occurred in those fed premature formulas high in caloric density; however, human milk bezoars have also been described. The formation of lactobezoars may be precipitated by the addition of thickening agents, such as gel of pectin, to the infant’s formula. Lactobezoars have also been reported in adults fed Osmolite (Ross Nutritionals, Columbus, Ohio).
Paper Bezoars
At least two case reports of paper bezoars, one in a child and one in an adult, have been described. The undigested material was toilet paper, ingested over several days.
Pharmacobezoars
A large number of case reports have documented the formation of concretions from various medications, leading to gastric bezoars. The medications implicated include nifedipine XL, sucralfate, bromide, enteric-coated aspirin, iron, meprobamate, slow-release theophylline, and antacids. Along with the typical obstructive symptoms of bezoars, these foreign bodies may induce symptoms based on their intrinsic pharmacologic effects. Bezoar formation is probably related to the composition of the inert compound found in the medication (e.g., cellulose). This has been a particular problem with medications packaged in insoluble material for long, continuous delivery of the active drug.
Cement Bezoars
Cement contains oxides of silica, aluminum, iron, and calcium; sulfuric anhydroxide; magnesium hydroxide; and calcium carbonate. Several cases of cement bezoars have been reported in young children, with the formation of solidified concretions. Different types of cement require various lengths of time to “set.” After this time has elapsed, attempts at gastric lavage are futile and surgery is required.
Yeast Bezoars
Yeast bezoars have been reported primarily in patients undergoing gastric surgery, particularly vagotomy, although one was described in a newborn and was composed of Candida albicans and polystyrene resin. Of the 43 patients with yeast bezoars reported in a Finnish study in 1974, 48% had undergone a Billroth I procedure and vagotomy. The most common species of fungi noted were Candida albicans and C. glabrata . Yeast bezoars are usually asymptomatic and are discovered incidentally. They have a tendency to recur.
Shellac Bezoars
Although glue bezoars have been described in experimenting adolescents, most shellac bezoars occur in adult alcoholics who drink shellac to intensify the effect of alcohol. Shellac can be found in furniture polish and is readily available to children.
Polybezoars
The term polybezoars refers to bezoars composed of multiple objects (metallic, plastic, or even wood) encased in trichobezoars. These usually are found in children or in neurologically impaired adults. Polybezoars often contain a large number of metal pins or clips .
Chewing Gum Bezoars
Although rare, three cases are reported in the literature of chewing gum bezoars. Two of these were chewing gum fecomas removed by manual disimpaction under anesthesia. The characteristic “taffy-pull” appearance of colorful material was diagnostic.
Clinical Presentation
A summary of the clinical manifestations of bezoars is shown in Table 29-2 . The initial presentation of many bezoars depends on their type. In premature infants and newborns, the most common bezoar is the lactobezoar. The most common symptom is feeding intolerance. With time, symptoms may include abdominal distension, irritability, and vomiting. Physical examination often discloses a palpable midabdominal mass.
| Characteristic | Incidence in Patients (%) |
|---|---|
| Halitosis | 20-40 |
| Abdominal/epigastric pain | 40-70 |
| Fullness after meal | 20-60 |
| Nausea/vomiting | 10-50 |
| Abdominal mass | 10-88 |
| Perforation/pneumatosis/acute abdomen | 7-10 |
| Dysphagia | 5 |
| Intestinal obstruction, partial or complete | ≤75 |
| Weakness/weight loss | 6-30 |
| Peptic ulcer disease | 10-24 |
| Hematemesis | ≤71 |
Trichobezoars and phytobezoars are more common in older children and adults. Trichobezoars form over long periods (several years). Early in the course, signs and symptoms can be subtle such as early satiety or nausea. These bezoars can grow to a substantial size and mass, causing pressure necrosis of the gastric mucosa, ulceration, gastrointestinal bleeding, and even gastric perforation. Most trichobezoars have “tails,” extending either into the esophagus or distally into the small intestine, which can lead to partial or complete obstruction. Trichobezoars can often be identified by abdominal palpation. Crepitus, caused by putrefaction from bacterial growth, may be elicited.
Phytobezoars are formed much more rapidly than trichobezoars. Symptoms include nausea, vomiting, and signs of gastric outlet obstruction, which may persist even after the bezoar has been removed. Serious complications, such as gastric perforation, are rare but have been the subject of case reports in both adult and pediatric populations. Not only may pharmacobezoars induce symptoms as a result of their gastric mass, but they also carry the potential for drug intoxication. Concretion in the duodenum and in the biliary tract can cause pancreatitis (toxic “sock” syndrome). Symptoms such as malabsorption and protein-losing enteropathy can also arise from bezoars in these locations.
Diagnosis
The diagnosis of bezoars in adolescents can often be made by history and physical examination. Infants and children require a thoughtful history and consideration of the diagnosis when evaluating nonspecific clinical findings. Knowledge of predisposing factors may heighten clinical suspicion. Laboratory studies are of limited value, although occasionally a mild microcytic anemia or leukocytosis may develop. Imaging studies such as plain abdominal radiographs are the initial diagnostic modality identifying most bezoars. Barium studies may be useful to identify the bezoar and to determine the extent of the mass ( Figure 29-2 ). However, upper gastrointestinal series may fail to diagnose bezoars in 36% to 50% of patients. Moreover, in a reported case of enteric-coated aspirin bezoar, the use of barium changed the acid environment, leading to its absorption and a subsequent increase in the salicylate level. Other methods, such as ultrasonography or CT, have also been used to document gastric bezoars. These studies do not add to the diagnostic accuracy. Endoscopy remains the diagnostic modality of choice for identifying the type of gastric bezoar. Endoscopy also allows for therapeutic intervention.
