Pathophysiological and clinical aspects of the diagnosis and treatment of bezoars

Temporal changes in computed tomography findings of a persimmon bezoar: A case report

BACKGROUND

Gastric bezoars are masses of indigestible material that accumulate in the stomach, causing nausea, abdominal pain, and vomiting. Persimmon bezoars (diospyrobezoars), which comprise tannins and fibers from persimmons, are relatively rare but may cause significant gastric complications, including gastric outlet obstruction or ileus. Although computed tomography (CT) is a useful imaging tool, diagnosing bezoars can be challenging because their density is similar to that of food debris and gastric content.

CASE SUMMARY

Here, we report the case of a 72-year-old woman with a persimmon bezoar that was diagnosed using serial CT imaging and confirmed by endoscopy. CT performed over several months revealed changes in the internal structure and density of the bezoar, suggesting progressive hardening. The patient had a history of a partial gastrectomy and excessive persimmon consumption, both of which are risk factors for bezoar formation. Endoscopic fragmentation of the bezoar successfully resolved symptoms.

CONCLUSION

Gastric bezoars, particularly persimmon bezoars, present diagnostic challenges because of their variable imaging characteristics. Serial CT can document temporal changes in bezoar density, potentially reflecting changes in hardness. Early diagnosis and endoscopic treatment are essential for effective management, particularly in patients with predisposing factors. This case underscores the importance of considering bezoars in the differential diagnosis of gastric masses, and highlights the value of CT for monitoring changes in bezoar characteristics over time.

Chronic intestinal pseudo-obstruction complicated with sand-like enterolithiasis: case report

Enterolithiasis is typically associated with gastrointestinal tract stasis. Here, we report on a rare case of chronic intestinal pseudo-obstruction with sand-like enterolithiasis in an 18-year-old Japanese female admitted to our hospital with high fever and abdominal pain. Despite initiating antibiotic treatment, the fever persisted. A contrast-enhanced computed tomography revealed colonic enlargement and a large amount of residue with a high-density area in the ascending colon. A colonoscopy revealed sand-like enteroliths in the ascending colon, which were drained using a colonoscope. The patient's symptoms improved significantly after the drainage and antibiotic therapy. The granules were white-brown in color and smaller than 300 μm in size. Infrared spectroscopy indicated similar peaks for crystals and hydroxypropyl cellulose which is an additive used in certain medications. We hypothesized that hydroxypropyl cellulose contributed to the formation of sand-like enteroliths in cases of severe intestinal dysmotility. Intestinal failure may cause enterolithiasis due to an unharmful additive and require careful follow-up.

Case Report on Rapunzel syndrome: a large gastric trichobezoar extending to the proximal jejunum in a young adult female

A trichobezoar is an intraluminal mass of hair growing continuously with additional ingestion, while Rapunzel syndrome refers to a giant gastric trichobezoar that extends from the stomach into the small intestine. We present a case of Rapunzel syndrome as an uncommon cause of upper gastrointestinal (GI) symptoms in a young adult woman who denied trichotillomania and trichophagia. Preoperative radiological assessment was pivotal in planning a preferable therapeutic approach. The patient underwent laparotomy and prepyloric gastrotomy, resulting in satisfactory postoperative outcomes. Trichobezoars are extremely rare and predominantly affect young women with underlying psychiatric conditions. Although uncommon, they cause severe upper gastrointestinal symptoms and may even lead to various complications. This case report helps in understanding the presentation of gastric trichobezoar and Rapunzel syndrome, including their range of symptoms, radiological appearance, and associated findings, to make an accurate diagnosis and guide an appropriate treatment approach.

Clinical Characteristics of Children With Foreign Bodies in the Digestive Tract and Analysis of Risk Factors for Serious Complications

Foreign bodies (FBs) in the digestive tract are common in children, we analyzed the clinical characteristics of children with FBs in the digestive tract and discuss the risk factors for serious complications. We retrospectively reviewed clinical data of 139 children with FBs in the digestive tract. Based on the severity of complications caused by FBs, the patients were divided into risk and general groups for analysis and comparison. Significant differences were observed in the retention sites of FBs, the diameter of FBs retained in the esophagus, FBs retention time exceeding 24 h, and the absence of witnesses between the 2 groups. Inadequate care, button batteries (BBs), ingested mmFBs, FBs retained in the esophagus, long-term retention, and giant gastric bezoars may cause serious complications. In addition to treating FBs and the complications, clinicians should emphasize the importance of childcare to prevent the ingestion of FBs.

Subtotal gastrectomy for giant gastric trichobezoar

We present the case of a 22-year-old patient with a relevant previous history of trichophagia (Rapunzel Syndrome) in adolescence who presented Giant Gastric Trichobezoar that required subtotal gastrectomy for its resolution.

Severe Airway Obstruction Caused by Esophageal Bezoar with Coca-Cola and Creon (Pancrelipase) in a Patient with Underlying Achalasia: A Comprehensive Case Report

Introduction

The occurrence of acute respiratory failure as a result of esophageal bezoars is a rare phenomenon. We present a patient who failed initial endoscopic intervention. Successful resolution was achieved through a novel approach involving a combination of Creon and Coca-Cola. Subsequently, the patient was diagnosed with achalasia, a condition that potentially contributed to the formation of the esophageal bezoar. Case Description. An 82-year-old man presented with respiratory distress, necessitating endotracheal intubation for airway protection. A chest computed tomogram (CT) showed pneumonia and a distended esophagus compressing the trachea, raising the possibility of an esophageal food bolus. Endoscopy revealed a severely dilated esophagus containing a significant amount of food and a phytobezoar in the lower esophagus. He failed various endoscopic techniques to remove the obstruction. Given the patient's poor surgical candidacy, he was started in a thrice-daily regimen of Creon dissolved in 165 mL of Coca-Cola, over a 4-day period. A subsequent endoscopy revealed no discernible evidence of food or bezoar. The patient was weaned from mechanical ventilation. A high-resolution esophageal manometry identified type 1 achalasia.

Conclusion

Esophageal food impaction leading to respiratory failure is rare. Endoscopy remains the mainstay approach. Surgical interventions carry significant risks. This case emphasizes the potential for noninvasive management in patients with esophageal bezoars and also underscores the significance of contemplating esophageal pathologies when addressing cases of respiratory failure. The use of Coca-Cola and Creon emerges as a safe, effective, and cost-efficient treatment, providing a feasible option when endoscopy proves unsuccessful before considering more aggressive interventions.

Avoid the Peel: Citrus Fruit Bezoar Causing Intestinal Perforation

We report a highly unusual case of small bowel obstruction in an 86-year-old man from ingestion of a citrus fruit, known as kumquats, which led to intestinal perforation and peritonitis. He initially presented with a one-day history of diffuse abdominal pain associated with nausea and feculent emesis after eating whole pieces of unpeeled kumquats. When symptoms of peritonitis evolved with a blood lactate of 5.1 mg/dL, he was urgently taken to the operating room for exploration. Multiple areas with fibrous exudates and full-thickness ulceration were encountered along the distal jejunum and proximal ileum, with a partially obstructing intraluminal mass in the distal ileum. Treatment involved resection of 70 cm of non-viable bowel, removal of the intraluminal mass, and surgical re-establishment of intestinal continuity. Unpeeled kumquats were confirmed to have caused these intestinal findings. The patient did well following the operation and has had no further problems referred to by this management.

Has Coca-Cola treatment become the first-line therapy for gastric bezoars, both in general and specifically for western countries?

Phytobezoars is a rare disease and less common in Western countries. The stomach is the primary site for these formations, and endoscopic treatment involving fragmentation and extraction has traditionally been the most effective approach. However, medical treatments using enzymatic and chemical agents, such as cellulase and Coca-Cola, aimed at dissolving the bezoars, have also been utilized, showing varying degrees of resolution success. Notably, the oral dissolution treatment with Coca-Cola has emerged as a promising, simpler, and more cost-effective method. The study by Liu et al represents an important step in clinical research on this topic, despite some limitations that need addressing for a more comprehensive understanding of its findings. Key considerations for future research include sample size calculation, endoscopic procedure details, outpatient vs. inpatient treatment, and detailed cost calculations. The study's exclusions, such as patients with upper gastric surgery, phytobezoars older than 14 d, and cases of gastroparesis, limit its applicability to broader populations, especially in Western countries. Given the promising outcomes of the Coca-Cola treatment, it's advocated as a first-line therapy for phytobezoars. Nonetheless, further research is essential to overcome these limitations. However special situations such as perforation or small bowel obstruction will require surgical treatment.

Rapunzel syndrome in children: a retrospective review of ten cases combined with literature review in a tertiary referral center

PURPOSE

Rapunzel syndrome is an uncommon condition in children, and its clinical features remain unclear. This study presents the largest single-center series of pediatric cases to date, with the objective of documenting the clinical characteristics and treatment approaches for children with Rapunzel syndrome.

METHODS

A retrospective study was conducted in children with Rapunzel syndrome from 2019 to 2023. We recorded age, gender, symptoms, locations of bezoar, complications, and treatment options.

RESULTS

Ten patients with Rapunzel syndrome were included. The median age was 9.1 years, with all of whom were female. The most common clinical symptoms were upper abdominal mass (90%), abdominal pain (80%), and nausea and vomiting (50%). Complications occurred in six cases (60%), including small bowel obstruction (20%), severe gastric dilatation (10%), intestinal perforation (10%), choledochodilation (10%), acute pancreatitis with cholecystitis (10%). Preoperative ultrasonography suggested low-echoic foreign bodies continuing to the jejunum or ileocecal region in five cases (50%). Preoperative gastroscopy attempted in four cases (40%) to remove the foreign bodies, all of which failed. All patients underwent surgical treatment, with nine cases undergoing gastric incision foreign body removal, and one case undergoing gastric incision foreign body removal combined with intestinal perforation repair. All patients recovered well. No recurrence was observed during follow-up.

CONCLUSION

The accuracy of ultrasound diagnosis in identifying Rapunzel syndrome is high; however, it may lead to misdiagnosis if not complemented with the patient's medical history. Endoscopic presents a heightened treatment risk and a reduced success rate. The condition commonly presents with severe complications, thus making laparotomy a safe and effective option for intervention.

Endoscopic lithotripsy combined with drug lithotripsy vs. drug lithotripsy for the treatment of phytobezoars: analysis of 165 cases

AIM

To analyze efficacy of endoscopic lithotripsy combined with drug lithotripsy as compared with drug lithotripsy for the treatment of phytobezoars.

METHODS

We collected and evaluated case records of 165 patients with phytobezoars from 2014 to 2023. And we analyzed demographic and clinical characteristics, imaging features, endoscopic features, complications of phytobezoars, and compared efficacy between endoscopic lithotripsy combined with drug lithotripsy (Group A) and drug lithotripsy (sodium bicarbonate combined with proton pump inhibitor) (Group B).

RESULTS

The median age of patients with phytobezoars was 67.84 ± 4.286 years old. Abdominal pain was the most common symptom and peptic ulcers (67.5%) were the most common complication. Bezoar-induced ulcers were more frequent in the gastric angle. The success rate of phytobezoars vanishing in Group A and Group B were similar (92.3% vs. 85.1% within 48 h, 98.7% vs. 97.7% within a week), while the average hospitalization period, average hospitalization cost, second endoscopy rate, and average endoscopic operation time were significantly lower in patients in Group B than in Group A.

CONCLUSION

Drug lithotripsy is the preferred effective and safe treatment option for phytobezoars. We advise that an endoscopy should be completed after 48 h for drug lithotripsy.

A Rare Case of Phytobezoar Related to Occupational Exposure

Bezoars constitute a compacted collection of undigested or partially digested material, potentially leading to intestinal obstruction. They most frequently occur in the stomach, with classification based on their composition. Many gastric bezoars are asymptomatic and frequently manifest in patients with gastrointestinal disturbances or psychiatric issues.  We present a rare case of a bezoar related to occupational exposure that illustrates the least-discussed health risks associated with certain jobs.

Trichobezoar Found Accidently while Diagnosing Resistance to Thyroid Hormone

Introduction

Bezoars are masses of indigestible foreign material in the gastrointestinal tract, usually in the stomach. These materials could be indigestible fruits, hair, milk products, or tablets. In children, the most common type of bezoar is trichobezoar (formed from hair).

Case Presentation

We describe a female patient who has been complaining about deterioration of mood, collapse without losing consciousness, scotomas, and cardiac arrhythmia for 2 years. Based on the results of thyroid hormone, resistance to thyroid hormone (RTH) was suspected. Physical examination during hospitalization revealed a palpable upper abdominal mass. Several diagnostic examinations were performed. The abdominal ultrasound showed acoustic shadowing caused by a pathological structure in the upper abdomen. Therefore, the contrast X-ray of the digestive tract revealed a deficit of contrast with an irregular shape in the stomach body and the pylorus region. Due to these results, a gastroscopy was performed, which revealed a large trichobezoar of the stomach. The trichobezoar was surgically removed without complications.

Conclusion

The case presented shows that these nonspecific symptoms and laboratory test suggesting RTH require multi-path diagnostics and the cooperation of many specialists, ultimately giving a surprising diagnosis. It is crucial to interpret diagnostic examinations with regard to the patient's physical condition. Diagnosis of trichobezoar requires a detailed search of causes to avoid another incident.

Expect the unexpected: bezoar-caused gastric perforation in the 19-year-old patient, after traffic accident

A 19-year-old female involved in a traffic accident presented to the Emergency Room (ER) with no trauma-related symptoms but a palpable mass in the epigastrium. Imaging revealed a massive trichobezoar causing gastric perforation. Urgent laparotomy was performed, and a 1.5-kilogram bezoar was removed, along with repairing coexisting gastric ulcers. The patient had a history of trichophagia, suggesting a psychiatric association. This case highlights the potential of trichobezoars to cause gastric perforation, even in patients admitted for unrelated reasons. CT-scan proves effective in diagnosing such cases. While a traffic accident might be a plausible cause, the presence of a bezoar can elevate the risk of complications. Psychiatric evaluation is recommended when trichophagia is identified. The study underscores the need for vigilance in unexpected scenarios, demonstrating the importance of multidisciplinary approaches in managing such cases.

Visualization of Gastrointestinal Bezoar Movement Causing and Releasing Small Bowel Obstruction on Computed Tomography in a Patient With Diabetes Mellitus

Although delayed gastric emptying promotes gastrointestinal bezoar formation in patients with diabetes mellitus (DM), the association between movement of gastrointestinal bezoars and glycemic status remains unclear. We report a case of small bowel obstruction (SBO) caused by impaction of the migrated gastric bezoar into the small bowel in a patient with DM. Correction of hyperglycemia and lactic acidosis led to normalization of gastrointestinal motility, followed by expulsion of the impacted bezoar and resolution of SBO. This case suggests a link between hyperglycemia, metabolic acidosis, and gastrointestinal motility based on visualization of gastrointestinal bezoar movement in the gastrointestinal tract using computed tomography.

A Rectal Sunflower Seed Bezoar Causing Fecal Impaction in a Healthy Young Woman

Bezoars, characterized by undigested or partially digested foreign bodies in the gastrointestinal (GI) tract, are a rare condition associated with significant complications. We present a case of a 31-year-old woman who sought medical attention due to weight loss, diarrhea, and anorectal pain. Upon investigation, she was diagnosed with fecal impaction caused by a rectal sunflower seed bezoar. The patient had a history of regular sunflower seed consumption, suggesting a potential association with the development of the bezoar. Fecal impaction resulting from the bezoar led to chronic constipation, contributing to the patient's weight loss and anorectal discomfort. Imaging studies, including abdominal X-rays or computed tomography (CT) scans, played a crucial role in confirming the diagnosis by identifying the presence of the bezoar within the rectum. Management involved a multidisciplinary approach, with gastroenterologists and colorectal surgeons. A flexible endoscope was utilized to visualize and remove the sunflower seed bezoar under direct vision, providing immediate relief from the symptoms. This case emphasizes the importance of considering bezoars as a potential cause of GI symptoms, even in young and otherwise healthy individuals. Although rectal bezoars are relatively rare, they can lead to significant morbidity. Therefore, it is essential to include them in the differential diagnosis of patients presenting with fecal impaction, anorectal pain, and associated symptoms. Prompt diagnosis, appropriate imaging, and early intervention are crucial for the successful management and prevention of potential complications and the improvement of patient outcomes.

A Single-center 12-year Experience of Patients with Gastrointestinal Bezoars

Background/Aims

Gastrointestinal (GI) bezoars are relatively rare diseases with clinical characteristics and treatment modalities that depend on the location of the bezoars. This study evaluated the clinical characteristics and treatment outcomes in patients with GI bezoars.

Methods

Seventy-five patients diagnosed with GI bezoars were enrolled in this study. Data were collected on the demographic and clinical characteristics and the characteristics of the bezoars, such as type, size, location, treatment modality, and clinical outcomes.

Results

Among the 75 patients (mean age 71.2 years, 38 males), 32 (42.6%) had a history of intra-abdominal surgery. Hypertension (43%) and diabetes (30%) were common morbidities. The common location of the bezoars was the stomach in 33 (44%) and the small intestine in 33 (44%). Non-surgical management, including adequate hydration, chemical dissolution, and endoscopic removal, was successful in 2/2 patients with esophageal bezoars, 26/33 patients with gastric bezoars, 7/9 patients with duodenal bezoars, and 20/33 patients with small intestinal bezoars. The remaining patients had undergone surgical management.

Conclusions

The management of GI bezoars requires multidisciplinary approaches, including the appropriate correction of fluid and electrolyte imbalances, chemical dissolution, and endoscopic and surgical treatments.

Mallory-Weiss syndrome from giant gastric trichobezoar: A case report

BACKGROUND

Mallory-Weiss syndrome (MWS), representing a linear mucosal laceration at the gastroesophageal junction, is a quite frequent cause of upper gastrointestinal bleeding, usually induced by habitual vomiting. The subsequent cardiac ulceration in this condition is likely due to the concomitance of increased intragastric pressure and inappropriate closure of the gastroesophageal sphincter, collectively inducing ischemic mucosal damage. Usually, MWS is associated with all vomiting conditions, but it has also been described as a complication of prolonged endoscopic procedures or ingested foreign bodies.

CASE SUMMARY

We described herein a case of upper gastrointestinal bleeding in a 16-year-old girl with MWS and chronic psychiatric distress, the latter of which deteriorated following her parents’ divorce. The patient, who was residing on a small island during the coronavirus disease 2019 pandemic lockdown period, presented with a 2-mo history of habitual vomiting, hematemesis, and a slight depressive mood. Ultimately, a huge intragastric obstructive trichobezoar was detected and discovered to be due to a hidden habit of continuously eating her own hair; this habit had persisted for the past 5 years until a drastic reduction in food intake and corresponding weight loss occurred. The relative isolation in her living status without school attendance had worsened her compulsory habit. The hair agglomeration had reached such enormous dimensions and its firmness was so hard that its potential for endoscopic treatment was judged to be impossible. The patient underwent surgical intervention instead, which culminated in complete removal of the mass.

CONCLUSION

According to our knowledge, this is the first-ever described case of MWS due to an excessively large trichobezoar.

Rectal Bezoar: A Rare Cause of Intestinal Obstruction

Bezoars are conglomerates of undigested contents that accumulate in the gastrointestinal tract. They can have different compositions, such as fibers, seeds, vegetables (phytobezoars), hair (trichobezoars), and medication (pharmacobezoars). Bezoars are typically caused by an impaired grinding mechanism of the stomach or interdigestive migrating motor complex, but the composition of ingested material can also play a role in their formation. Gastric dysmotility, previous gastric surgery, and gastroparesis are some of the risk factors that can increase the likelihood of developing bezoars. While bezoars are usually asymptomatic and found in the stomach, they can sometimes migrate to the small intestine or colon and cause complications such as intestinal obstruction or perforation. Endoscopy is essential for diagnosis and etiology, and treatment depends on the composition, which can include chemical dissolution or surgical intervention. We present a case of an 86-year-old woman, who had a bezoar located in an unusual location (rectum), most likely due to migration. This condition led to symptoms of intermittent intestinal obstruction and rectal bleeding. However, due to anal stenosis, the patient was unable to expel the bezoar. Its removal was not possible through various endoscopic techniques. Therefore, it was removed via fragmentation, using an anoscope and forceps, due to its hard/stone-like consistency. This case highlights the importance of considering bezoars in the differential diagnosis of gastrointestinal bleeding and illustrates the importance of prompt diagnosis and appropriate techniques for the removal of bezoars.

Multidisciplinary treatment of massive trichobezoar caused an acute gastric outlet obstruction

Introduction. Trichobezoars presents a rare form of bezoar made of swallowed hair, with clinical manifestation of gastric or intestinal obstruction, gastric ulceration, bleeding, and perforation. It is predominantly found in emotionally disturbed or mentally retarded youngsters, who eating their own hair which is clinically known as trichophagia. Patients often deny eating their own hair which makes diagnosis difficult. Case report. We present a case of acute gastric outlet obstruction caused by a giant gastric trichobezoar made of a long thin hair, in a 20-year young female. Although patient had a long history of trichophagia, she did not think her behavior was unusual and she had not been treated before. Following the initial diagnostic procedures, exploratory laparotomy was indicated. After anterior gastrotomy was performed, a massive stomach-shaped trichobezoar was removed. Postoperatively, the patient had a psychiatric consult exam. She recovered well and was discharged without complications. She was referred for further psychiatric follow-up. Conclusion. Trichobezoars are non-digestible collections that usually accumulates in stomach and can extend to small bowel, causing mechanical injury such as hollow viscus obstruction. Patients with acute gastric obstruction caused by a giant trichobezoar require urgent removal of the trichobezoar, to preserve the stomach and avoid further, catastrophic consequences.

Failure of Computed Tomography (CT) in Detecting an Aspirin Pharmacobezoar: A Case Report

BACKGROUND Prior studies suggest CT can identify bezoars under certain circumstances. Endoscopy provides diagnostic and therapeutic benefit in the setting of suspected aspirin bezoar. Does the absence of findings on CT scan exclude the presence of an aspirin bezoar? CASE REPORT A 64-year-old woman called the police and stated she ingested a bottle of aspirin to harm herself. Upon arrival to the Emergency Department, she was tachypneic with a GCS of 15. Initial laboratory results were: salicylate level of 1143 mcg/mL, respiratory alkalosis, bicarbonate of 9 meq/L, anion gap of 23, and normal renal function. Initial therapeutic intervention included infusions of glucose and bicarbonate, multiple doses of activated charcoal, intubation, and emergent hemodialysis. After hemodialysis, the salicylate level rebounded, and a Gastroenterology (GI) consultation was requested to rule out bezoar. On day 2, GI requested an abdominal CT scan with Gastrografin in place of endoscopy due to hemodynamic instability. A CT scan was negative for bezoar. After multiple hemodialysis sessions and whole-bowel irrigation with rebounding salicylate levels, GI was consulted again for reevaluation for endoscopy. On day 5, an endoscopy discovered a concretion containing pill fragments. Another endoscopy performed on day 7 removed further fragments. Salicylate levels began to consistently decline. Unfortunately, the patient's neurologic status did not improve, and on day 11 she was switched to palliative care and died. CONCLUSIONS Endoscopy with direct visualization is diagnostic and therapeutic in the setting of a possible bezoar. The absence of pharmacobezoar on imaging should not delay endoscopy in a clinical setting suggesting bezoar.

Gastric Xylobezoar Treated with Continuous Enteral Coca-Cola® Infusion

Xylobezoar is a rare clinical condition in which undigested paper becomes trapped in the gastrointestinal tract causing varying degrees of gastrointestinal obstruction. This condition can be suspected in children with a history of gastric surgeries, decreased gastrointestinal motility, or pica. Xylobezoar presents with symptoms ranging from chronic abdominal pain to gastrointestinal perforation. Surgical intervention is often required as endoscopic removal is challenging and not always successful. Chemical dissolution has been shown to be effective in treating certain bezoars. Here, we report a case of a pediatric patient with xylobezoar who was successfully treated with continuous enteral Coca-Cola® infusion.

Non-traumatic adult acute abdomen with high-attenuation lesions or materials in the gastrointestinal tract on unenhanced computed tomography

Computed tomography (CT) is an imaging modality that provides otherwise unobtainable information in the diagnostic workup for acute abdomen. The patient's clinical history, physical examination, and laboratory findings are essential for a correct diagnosis; however, some diagnoses are difficult to establish. Although contrast-enhanced CT is the preferred diagnostic tool and provides invaluable information, using only post-contrast images can lead to misdiagnoses. Unenhanced CT images are more useful than post-contrast images for detecting high-attenuation lesions or materials because surrounding tissues also show high attenuation on post-contrast images. Unenhanced CT often provides key imaging findings for a correct diagnosis; hence, the purpose of this article is to describe CT findings in acute abdomen with high-attenuation lesions in the gastrointestinal tract.

Self-made wire loop snare successfully treats gastric persimmon stone under endoscopy

BACKGROUND

Large gastric persimmon stones are generally resistant to standard endoscopic treatments. We applied an alternative endoscopic method using a hand-made snare for the treatment of large gastric phytobezoars.

AIM

To explore the clinical efficacy of a self-made wire loop snare to treat giant gastric persimmon stones.

METHODS

A retrospective study evaluated the clinical data of 38 patients with gastroliths admitted to Taihe Hospital in Shiyan City, Hubei Province, China, between March 2015 and October 2020. The patients were divided into observation (n = 23) and control (n = 15) groups. Patients in the observation group were treated with self-made wire loop snares for lithotripsy, and patients in the control group were treated with traditional foreign body forceps, snares, injection needles, and other tools. Successful stone removal, treatment time, and hospital stay were compared.

RESULTS

The average operating time was significantly shorter (P < 0.001) in the observation group (53.4 min) than that in the control group (172.8 min). The average hospital stay of the observation group (5.4 d) was significantly shorter (P < 0.001) than that in the control group (10.3 d). Successful one-time treatment was significantly more frequent (P < 0.001) in the observation group (87%) than in the control group (7%).

CONCLUSION

Self-made guidewire loop snares were successfully used to treat gastrolithiasis, and were significantly more effective than foreign body forceps, snares, and other traditional methods.

Treatment of Children Trichobezoar a Retrospective Study of 11 Cases

PURPOSE

The goal of this study to summarize the clinical features, treatment and prognosis of children trichobezoar, and to guide the clinical diagnosis and treatment.

METHODS

The clinical manifestations, auxiliary examination results, diagnosis and treatment process and family relationship of 11 cases of children with trichobezoar in our hospital were analyzed retrospectively.

RESULTS

11 cases were female, 4 cases were divorced single parent family, and 2 case was left behind child. Six patients were admitted to hospital with sudden exacerbation of chronic abdominal pain, and four of them had recurrent vomiting. Five patients were admitted to hospital with acute abdominal pain, and 3 of them had vomiting symptoms; The weight of 1 case was lower than -2 SD, 4 cases were between -2 SD ~ -1 SD. 6 cases had palpable left upper abdominal mass with mild tenderness, 1 case only had left upper abdominal tenderness, 4 cases had no positive abdominal signs; The results of color Doppler ultrasonography in 8 children indicated the strong echo mass in the stomach, and 3 of them showed that the hyperechoic group extended to duodenum through pylorus. 7 cases had a tail end extending into the small intestine after removing the gastrolith during the operation. Four cases were found with jejunal perforation, 2 cases were treated with intestinal resection and anastomosis, and 2 cases were treated with intestinal repair. All the children were improved and discharged after operation.

CONCLUSION

For single parent families or left behind children with a history of chronic abdominal pain, vomiting and trichophilia, gastric hair stones should be highly suspected. For large hair stones in the stomach, they should be removed surgically. During the operation, the small intestine should be explored routinely to prevent the missed diagnosis of small intestinal perforation. Psychological guidance should be given to the children and their parents to prevent recurrence.

POCUS Finding of Portal Venous Gas: An Unusual Consequence of an Amyloid Dysmotility Related Bezoar

A 73-year-old male with a recent finding of pericardial effusion and syncope was evaluated with point of care ultrasound for recurrent effusion. A thickened left ventricle and recurrent pericardial effusion were found. Unexpectedly, on scanning the inferior vena cava (IVC), extensive portal venous gas was identified, a finding previously described as a "meteor shower". Subsequent imaging by computed tomography (CT) identified gastric edema and peri-gastric vessel gas as the source of the portal gas, attributed to a large bezoar. The bezoar was later classified as a phytobezoar and the patient was found to have both cardiac and gastrointestinal manifestations of light chain amyloidosis. The gastrointestinal amyloidosis predisposed the patient to bezoar formation owing to associated dysmotility, a rare complication of an unusual manifestation of systemic amyloid.

Opioid Overdose and Serotonin Syndrome due to Gastric Bezoar in a Woman with Autism and Pica Behaviour

We are presenting the case of a 38-year-old woman with nonverbal autism and intellectual disability, hospitalized in a neurobehavioural unit because of a pica behaviour for 3 years. During the hospitalization, the patient presented an episode of pain, agitation, restlessness, rhabdomyolysis, coma, tachycardia, hyperthermia, shivering, and diarrhoea. The main hypothesis raised was tramadol overdose because of the immediate antidote response to the injection of naloxone 0,4 mg/mL. Even if we did not exceed the recommended prescription dosage of tramadol, the presence of gastric bezoar slowed the absorption of the drug, and the consequence was an opioid overdose and serotonin syndrome.

Bezoar: an uncommon cause of upper gastrointestinal bleeding

Bezoars are aggregates of non-digestible material that accumulate in the gastrointestinal tract. They can be classified according to their composition, and phytobezoars (composed of vegetable or fruit fiber) is the most common type. They most often occur in patients with some risk factors, namely prior gastric surgery, neuropsychiatric, endocrine or other disorders that lead to abnormal gastric function, or poor gastric peristalsis. Bezoars may be asymptomatic but most commonly cause abdominal discomfort or pain, nausea, vomiting, fullness, difficulty in swallowing, or anorexia and weight loss. Upper GI endoscopy for both diagnostic and therapeutic purposes is key in the management of bezoars.

Gastro-esophageal pharmacobezoar

A 35-year-old man with schizophrenia died from an overdose of propranolol (blood level = 60 mg/L). Post mortem CT scanning showed marked distension of the esophagus by granular material with a bolus of similar material within the stomach. At autopsy 62 g of lime green pharmacobezoar was present within the esophagus with an additional 130gm mass of similar material within the stomach, both of which contained propranolol. The rest of the gastrointestinal tract was unremarkable. The mouth, pharynx, glottis, larynx, trachea and bronchi were all structurally normal with no obstructive material. Thus, there was no evidence of airway compromise to suggest that the bezoar had mechanically contributed to death. Rather, elution of the drug had resulted in lethal blood levels. The color of the pharmacobezoar derived from the green color of certain propranolol tablets. Death was therefore attributed to propranolol toxicity with an associated finding of a massive gastro-esophageal pharmacobezoar.

Trichobezoar

Teaching point: A trichobezoar is a relatively rare entity that presents on imaging as a heterogeneous and multilayered mass molded by the stomach lumen.

Acute pancreatitis and small bowel obstruction caused by a migratory gastric bezoar after dissolution therapy: A case report

BACKGROUND

Bezoars are conglomerates of indigestible foreign material that can be found in the gastrointestinal tract. Gastric ulcer, gastrointestinal perforation, and intestinal obstruction are the main complications. Acute pancreatitis secondary to bezoar is rare. Here, we present a rare case of a migratory gastric bezoar complicated by acute pancreatitis and small bowel obstruction after dissolution therapy.

CASE SUMMARY

A-65-year-old woman underwent gastroscopy because of epigastric pain, which revealed a huge bezoar and a gastric ulcer 10 d prior. The patient was discharged with a prescription of drinking 1 L Coca-Cola daily for 6 d, without repeat gastroscopy. However, she suddenly developed epigastric pain, nausea and vomiting for 3 d. Abdominal computed tomography (CT) revealed mild inflammation of the pancreas. Magnetic resonance cholangiopancreatography showed no abnormalities in the pancreatic duct or common bile duct. The nasogastric tube still showed drainage of more than 1.6 L of dark fluid each day after symptomatic treatment. Abdominal CT re-examination suggested intestinal obstruction. Esophagogastroduodenoscopy revealed a huge yellowish hard mass in the jejunal lumen, and we used the basket and net to fragment the bezoar. She was discharged with a good outcome.

CONCLUSION

Endoscopic therapy is the first choice for gastric bezoars. When mechanical disintegration cannot be achieved, timing of repeat endoscopy is important during Coca-Cola dissolution therapy.

Gastric phytobezoars as a very unusual cause of gastric outlet obstruction

Bezoars are collections of indigestible foreign material found in the gastrointestinal tract. Phytobezoars are the most common among the types of bezoars. Treatment of phytobezoars is categorized into four types: chemical dissolution, endoscopic removal, adjuvant prokinetics, and surgery. Complications from phytobezoars can include gastric outlet obstruction (GOO), ileus, ulcerations, gastrointestinal bleeding, and perforation. Herein, we present an 86-year-old woman with refractory postprandial vomiting. Then, exploratory laparotomy was performed and the diagnosis was gastric phytobezoar. Phytobezoars-induced GOO is rare and its diagnosis is still a challenge.

Phytobezoar: A train can hide another

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A very rare cause of acute intestinal obstruction without diagnostic peculiarities.

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The patient's particular profile and his past medical history should mainly guide the diagnosis.

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The abdominal CT scan can improve the diagnosis, but it should not delay management.

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Exploring the entire digestive tract intraoperatively is an imperative procedure that can be life-saving.

Introduction and importance

Acute bowel obstruction is a life-threatening condition; late or incomplete management worsens the prognosis. Bezoars are a rare etiology of this disease, and the diagnosis can be confusing. This study aims to present and discuss a very rare case of concomitant bezoars.

Case presentation

We report the case of a 22-year-old male with a history of mental retardation who was admitted to the emergency department for acute intestinal obstruction with diffuse abdominal guarding. Laboratory findings revealed a biological inflammatory syndrome and an electrolyte imbalance. The abdominal X-ray was without abnormalities. Intraoperatively, a phytobezoar in the jejunum was initially discovered. However, the entire digestive tract's meticulous exploration discovered a concomitant vegetable bezoar in the stomach.

Clinical discussion

Phytobezoar obstruction is very rare and usually located in the distal small bowel, related to the reduced intraluminal diameter, the decreased mobility, and the higher water absorption in this portion. The clinical presentation is non-specific and reflects acute intestinal obstruction in the majority of cases. The abdominal CT-scan is useful for diagnosis. However, Surgeons should not delay the intervention until they recognize the etiology preoperatively because it is not always obvious. Besides, surgeons should explore the entire gastrointestinal tract during the intervention; a second phytobezoars' location is undoubtedly exceptional but exists, as evidenced by our case.

Conclusion

When phytobezoar obstruction, urgent care is required, and the intraoperative exploration of the entire digestive tract is a simple gesture with capital importance. It allows to prevent avoidable complications, especially a second surgery.

Risk factors, endoscopic findings, and treatments in upper gastrointestinal bezoars: multi-center experience in Iran

AIM

The current study aimed to investigate the risk factors, endoscopic findings, and treatments of upper gastrointestinal bezoars.

BACKGROUND

Bezoars are compact masses formed by the accumulation of dietary fiber, undigested food, hair, or medications. The majority of bezoars are asymptomatic, but they may cause serious symptoms or even life-threatening events such as bleeding, obstruction, or perforation.

METHODS

This retrospective study was conducted in three gastroenterology clinics between January 2016 and December 2019. Bezoars were detected in 109 of 15,830 endoscopy records (0.68%).

RESULTS

A total of 103 patients (52.4% male) were enrolled in this study. Mean patient age was 60.5±11.3 years. The most frequent risk factors were history of gastric surgery (25.2%), diabetes mellitus (21.3%), hypothyroidism (15.5%), trichophagia (5.8%), and anxiety disorders (2.9%), respectively. The most common endoscopic findings were peptic ulcers (34.9%), erosive gastritis/duodenitis (12.6%), and reflux esophagitis (10.6%). While bezoars were most commonly observed in the stomach (84.4%), the majority of them were phytobezoars (92.2%). The mean number of endoscopic interventions for each patient was 1.5 (range, 1-4). Endoscopy was successful in removing bezoars in 85.4%.

CONCLUSION

The synergistic effect of multiple factors for a long time, such as gastrointestinal surgery, diabetes mellitus or psychiatric disorders, may lead to bezoar formation. These risk factors should be avoided or treated in order to prevent bezoar formation and subsequent life-threatening complications.

Phytobezoar-induced small bowel obstruction in an elderly patient undergoing dialysis: a case report

A phytobezoar is defined as an accumulation of poorly digested fruit and vegetable fibers in the gastrointestinal tract. Phytobezoar-induced small bowel obstruction is an uncommon entity and is usually removed surgically. We herein describe an elderly man undergoing dialysis who developed a phytobezoar because of excessive consumption of high-fiber fruits and inappropriate chewing. His potential predisposing factors were dialysis-related lifestyle changes, reduced activity levels, fluid restriction, and gastrointestinal motility dysfunction; however, he had no history of gastric surgery. The patient’s clinical history and characteristic imaging features aided in the diagnosis. He underwent medical treatment, and his recovery was uneventful. This case highlights the importance of an awareness of phytobezoar-induced small bowel obstruction in patients at increased risk of developing bezoars and demonstrates that this condition can occur in the absence of previous gastric surgery. We believe that elderly patients undergoing dialysis are at increased risk of developing bezoars. Excessive consumption of a strictly fibrous diet and insufficient chewing exacerbate the risk. A detailed dietary history and imaging features can aid in early diagnosis, leading to appropriate medical or surgical care. Surgical treatment is not inevitable in all cases. Individualized dietary suggestions in these patients are important for effective preventive control.

Clinical and Forensic Aspects of Pharmacobezoars

BACKGROUND

Pharmacobezoars are specific types of bezoars formed when medicines, such as tablets, suspensions, and/or drug delivery systems, aggregate and may cause death by occluding airways with tenacious material or by eluting drugs resulting in toxic or lethal blood concentrations.

OBJECTIVE

This work aims to fully review the state-of-the-art regarding pathophysiology, diagnosis, treatment, and other relevant clinical and forensic features of pharmacobezoars.

RESULTS

Patients of a wide range of ages and of both sexes present with signs and symptoms of intoxications or more commonly gastrointestinal obstructions. The exact mechanisms of pharmacobezoar formation are unknown but are likely multifactorial. The diagnosis and treatment depend on the gastrointestinal segment affected and should be personalized to the medication and the underlying factor. A good and complete history, physical examination, image tests, upper endoscopy, and surgery through laparotomy of the lower tract are useful for diagnosis and treatment.

CONCLUSION

Pharmacobezoars are rarely seen in clinical and forensic practice. They are related to controlled or immediate-release formulations, liquid, or non-digestible substances, in normal or altered digestive motility/anatomy tract, and in overdoses or therapeutic doses, and should be suspected in the presence of risk factors or patients taking drugs which may form pharmacobezoars.