Bezoars

General

• FB forming due to accumulation of ingested material
• Leads to a hard mass/concretion in the stomach

Classification

• Phytobezoars - vegetable matter
• Trichobezoar - hair
• Pharmacobezoar - medications

Aetiology

• Impaired grinding mechanism of stomach
• Impaired interdigestive migrating motor complex
• Hypermotility
• Hair sticks in folds of stomach, turned black by gastric acid then combines with fibrous foods to form an enmeshed mass
• Related to gastroparesis, gastric surgery, GOO, vagotomy and use of meds with enteric coating

Clinical

• Insidious development of sx
• GIT - early satiety, AP, N+V
• General - fatigue, weight loss
• Oral - halitosis (due to bacterial colonization of trichobezoars)

Complications

• GI bleeding - ulcers (peptic ulcers or pressure necrosis)
• Obstruction
• Examination - mass, halitosis

Investigations

• Usually detected incidentally on imaging - xrays, CT, barium swallow
• OGD to sample and treat

Management

• Pharmacobezoars
  • Consider the specific drug and its toxicity
• Chemical dissolution
  • 3L coke over 12 hours
  • Cellulase
  • With prokinetic
  • DONT use papain (meat tenderizer) can cause ulcers/perforation
• Endoscopic fragmentation
  • Water jet
  • Direct suctioning through large channel
  • Forceps
  • Snares
  • Risk - delayed SBO, perforation bleeding
• Surgery
  • Only needed for complication or failure or medical/endoscopic mx
• Prevent recurrence - hydration, diet, psych stuff
  • High water intake
  • Modify diet - type of foods, avoid stringy fibre
  • Chew food
  • Psych assessment if indicated

Phytobezoar = Vegetable material

• Aetiology
  • Post-gastric surgery who have delayed gastric emptying
  • Diabetics
• Gastric bezoar presentation
  • Early satiety, nausea, pain, vomiting, weight loss
  • May have large mass on palpation
• Investigations
  • Confirm diagnosis with endoscopy or barium study
• Management
  • Attempt enzymatic degradation Coca-cola, celullase or Papain
  • Followed by endoscopic fragmentation
  • Failure necessitates surgery

Trichobezoars = Hair

• Generally long haired females
• Trichophagy = Eating one’s own hair, may need psychiatric care to prevent recurrence
• Presentation
  • Pain/bleeding from GU, gastric outlet obstruction
  • Occasionally present with gastric perforation and SBO
• Pathophysiology
  • Hair forms cast of the stomach
• Management
  • Small trichobezoars may respond to endoscopic fragmentation, lavage, or enzyme therapy
  • Large ones require surgical removal
    • Remember to examine small bowel to ensure additional bezoars are not present