Review of the diagnosis and management of gastrointestinal bezoars

A Case of Delayed and Persistent Carbamazepine Overdose Treated With Hemodialysis, Plasmapheresis, and Neostigmine

Carbamazepine is utilized for various indications. Due to its pharmacokinetic profile and drug properties, toxicity can be delayed and persistent despite supportive care. We report a severe case of intentional carbamazepine toxicity in a carbamazepine naive individual mimicking brain death that was not diagnosed until three days after consumption of carbamazepine when the patient was comatose. Symptoms of overdose persisted for several days despite attempted treatment with activated charcoal and whole bowel irrigation, hemodialysis, and plasmapheresis. Symptoms only began to improve with bowel evacuation as a result of administration of neostigmine intravenously plus hemodialysis and plasmapheresis additionally. Despite previous literature that reported success with hemodialysis and/or plasmapheresis we did not find either to be overly effective in our case possibly due to lack of ability to perform multidose activated charcoal and whole bowel irrigation. To our knowledge this is one of the few cases of carbamazepine overdose utilizing both hemodialysis and plasmapheresis but without activated charcoal and the only case report in which neostigmine was administered as an attempt to remove drug via the gastrointestinal tract with success.

Novel approach to managing two enormous bezoars with successive snare-tip electrocautery: A case report

BACKGROUND

Gastric bezoars are indigestible masses that can lead to gastrointestinal obstruction and ulceration. Standard treatments include endoscopic mechanical lithotripsy with a polypectomy snare and Coca-Cola dissolution therapy or a combination of both approaches. However, giant bezoars frequently require multiple treatment sessions and extended hospital stays. Additionally, snare-based mechanical fragmentation may be limited by factors such as bezoar size, shape, density, slipperiness, and restricted working space. In cases where refractory giant bezoars are unresponsive to traditional methods, surgical intervention is often necessary.

CASE SUMMARY

A 57-year-old male with a history of type 2 diabetes presented with severe epigastric pain and vomiting. Endoscopy revealed two large phytobezoars and a gastric ulcer. Initial attempts at mechanical fragmentation with a polypectomy snare and Coca-Cola ingestion for dissolution were unsuccessful due to the large size and complex structure of the bezoars. An innovative approach using snare-tip electrocautery was then employed. It successfully penetrated the slippery, hard surface of the bezoars and fragmented them into smaller pieces. The patient was subsequently treated with Coca-Cola ingestion, enzyme supplements, and proton pump inhibitors. He was discharged without complications following the endoscopic sessions.

CONCLUSION

Snare-tip electrocautery is a safe, cost-effective, and minimally invasive alternative for managing large, refractory gastric bezoars. This is a valuable option in resource-limited settings.

Rapunzel syndrome leading to acute intestinal obstruction in a teenager: A rare case report

INTRODUCTION AND IMPORTANCE

Trichobezor is a mass of accumulated ingested hair in the gastric lumen. Rapunzel syndrome is an extension of these bezoars beyond the pylorus. The formation of trichobezoar is invariably linked to trichotillomania and trichophagia. Convergence of trichotillomania and trichophagia resulting in the formation of massive trichobezoar and causing acute intestinal obstruction is a rare clinical manifestation. This case report aims to shed light on diagnostic intricacies and prompt management of such exceptional cases.

CASE PRESENTATION

This case report features a 13-year-old girl who presented to the surgical emergency department with complaints of abdominal pain, nausea, vomiting, and epigastric fullness for 5-6 months. She also described tufts of hair in vomitus and stools for the past few weeks. Due to these symptoms, she started experiencing significant weight loss, pallor, and pedal edema. Her Investigations revealed a large trichobezoar causing gastrointestinal obstruction and she was managed with exploratory laparotomy and gastrotomy followed by multidisciplinary care.

CLINICAL DISCUSSION

Trichobezoar develops secondary to trichotillomania and trichophagia. These disorders are deeply rooted in psychosocial stressors. This unique presentation highlights the need for awareness regarding such rare causes of intestinal obstruction.

CONCLUSION

Psychosocial stressors, trichotillomania, and trichophagia often go unnoticed in teenagers resulting in drastic consequences. A multidisciplinary approach is required to diagnose and manage gastrointestinal obstruction secondary to Rapunzel Syndrome.

Untangling rapunzel syndrome: A unique presentation of gastric trichobezoar

INTRODUCTION AND IMPORTANCE

Rapunzel syndrome is a rare condition that results from trichotillomania (compulsive hair pulling) and trichophagia (hair eating), causing a trichobezoar (hairball) to form This syndrome typically affects young females with psychiatric conditions and presents with symptoms like chronic abdominal pain, nausea, vomiting, and malnutrition. The condition is often diagnosed late, leading to serious gastrointestinal complications.

CASE PRESENTATION

A 19-year-old female from a rural community presented with chronic abdominal pain, vomiting, and nutritional deficiencies, including scaly skin and koilonychia. Over time, her symptoms worsened, and she discovered a palpable abdominal mass. Clinical evaluation, including an upper gastrointestinal endoscopy, revealed a large trichobezoar extending from the lower esophagus to the pylorus. The patient had a history of pica and compulsive behaviors, suggesting psychiatric involvement.

CLINICAL DISCUSSION

The endoscopy revealed a 20 × 13.5 × 9 cm trichobezoar. After successful surgical removal, the patient's gastrointestinal symptoms improved. Post-operatively, she received nutritional support and was referred for psychiatric evaluation to manage trichotillomania and trichophagia, with the aim of preventing recurrence in a private practice setting.

CONCLUSION

This case highlights the need for early recognition of Rapunzel syndrome in patients with chronic gastrointestinal symptoms and nutritional deficiencies. A multidisciplinary approach is essential for effective management and preventing recurrence.

Successful treatment of small bowel phytobezoar using double balloon enterolithotripsy combined with sequential catharsis: A case report

BACKGROUND

Small bowel bezoar obstruction (SBBO) is a rare clinical condition characterized by hard fecal masses in the small intestine, causing intestinal obstruction. It occurs more frequently in the elderly and bedridden patients, but can also affect those with specific gastrointestinal dysfunctions. Diagnosing SBBO is challenging due to its clinical presentation, which mimics other intestinal obstructions. While surgical intervention is the typical treatment for SBBO, advancements in endoscopic techniques have led to increased use of non-surgical methods, such as endoscopic lithotripsy.

CASE SUMMARY

We report a case of small bowel obstruction induced by a phytobezoar. A 49-year-old male with a history of type 2 diabetes and long-term persimmon consumption presented to the hospital with symptoms of vomiting, abdominal distension, and constipation. Computed tomography revealed a small bowel obstruction with foreign bodies. Double balloon enteroscopy identified a phytobezoar blocking the intestinal lumen. The bezoar was successfully fragmented using a snare, and the fragments were treated with 100 mL of paraffin oil to facilitate their passage. This case report aims to enhance the understanding of this rare condition by detailing the clinical presentation, diagnostic process, and treatment outcomes of a patient with SBBO. Special attention is given to the application and effectiveness of non-surgical treatment methods, along with strategies to optimize patient management.

CONCLUSION

Double balloon enteroscopy combined with sequential laxative therapy is an effective approach for the treatment of a breakable phytobezoar.

Historical Drugs in Transylvania: Disclosing the Composition of Ointments from the "History of Pharmacy Collection" in Cluj-Napoca Through a Multi-Analytical Approach

The National Museum of Transylvanian History in Cluj-Napoca, Romania, features a History of Pharmacy Collection that documents the evolution of pharmacies in the region since the 16th century. Within the "Pharmatrans" project (2021-2023), we investigated the chemical composition of ointments from fourteen historical pharmaceutical containers dating back to the 18th and 19th centuries. Most samples were from an aristocratic traveling medicine chest, a key artifact in the collection. This study marks the first extensive analysis of historical pharmaceutical formulations in Romania, enhancing our understanding of these valuable items. The main ingredients of formulations were characterized using gas chromatography-mass spectrometry (GC-MS), solid-phase microextraction-GC-MS (SPME-GC-MS), and pyrolysis-GC-MS (Py-GC-MS). Additionally, high-performance liquid chromatography coupled with high-resolution mass spectrometry (HPLC-ESI-Q-ToF) was employed for the detailed analysis of lipid materials and polar compounds. Elemental analysis was conducted using field emission gun-scanning electron microscope (FEG-SEM) with energy-dispersive spectroscopy (EDS). The results revealed that twelve out of fourteen mixtures contained interpretable organic content, often aligning with the vessels' labels. The findings indicate that Transylvanian elites in the late 18th century had access to both rare drugs and traditional remedies, reflecting contemporary trends in pharmacy.

A giant luminal bezoar treated by mechanical lithotripsy using a yellow zebra guide wire

Endoscopic fragmentation or removement of gastric bezoar is the simplest, most cost-effective approach, while the traditional endoscopic device include foreign body forceps, polypectomy snare, laser lithotripsy, and electrohydraulic lithotripsy. For bezoar < 3 cm, traditional snares are preferred. But for some giant or hard bezoars, traditional snares are too easily deformed to be used continuously and can be embedded in the bezoar causing direct damage to the stomach , Therefore, a handy and effective snare-like approach is needed, especially for elderly patients who have a high surgical risk. The lithotriptic device should be evaluated according to the size and texture of the gastroliths before lithotripsy. For some relatively hard gastroliths, which are easy to damage the endoscope, the use of transparent caps is a wise choice, which can protect the mirror body well. In this case, the bezoar was oversized (6 cm) and traditional snare was failed to capture the bezoar. Laser lithotripsy and electrohydraulic lithotripsy were lacking supplies and were not promptly available in our hospital. Therefore, we chose a yellow zebra guide wire to make this large snare for lithotripsy completely and removed with the assistance of gastric bezoar basket. The case highlights the importance of regular endoscopic instruments.

A giant trichobezoar in a child with attention deficit hyperactivity disorder: A case report

INTRODUCTION AND IMPORTANCE

Trichobezoars are uncommon gastrointestinal concretions that develop due to the accumulation of ingested hair, predominantly affecting young females with concurrent psychiatric conditions like trichotillomania and Trichophagia. These masses typically form in the stomach but may also protrude into the intestines, potentially leading to severe complications if not promptly identified and treated. The present case study outlines the clinical manifestation, diagnostic complexities, surgical intervention, and postoperative care of a 10-year-old female patient with a substantial gastric trichobezoar, underscoring the significance of considering this disorder in pediatric individuals with gastrointestinal manifestations and a psychiatric history.

CASE PRESENTATION

The research article details the case of a 10-year-old female patient with a multifaceted medical history, which includes attention-deficit/hyperactivity disorder (ADHD), chronic constipation, growth retardation, and a background of neonatal seizures. She was admitted to the emergency department presenting with epigastric pain, nausea, and vomiting. Notably, the patient displayed pica-like behaviors, specifically the ingestion of hair, which ultimately led to the diagnosis of a trichobezoar, a form of gastric obstruction resulting from the accumulation of ingested hair. Diagnostic imaging techniques, including abdominal X-ray and computed tomography (CT) scan, confirmed the presence of a substantial trichobezoar within the stomach, necessitating surgical intervention via exploratory laparotomy for removal. The pathological examination of the excised mass revealed a considerable quantity of hair intermingled with fecal matter. Following the surgical procedure, the patient exhibited a positive recovery trajectory and was subsequently referred for psychiatric assessment and behavioral therapy to address the underlying issues associated with trichotillomania, with the objective of preventing future occurrences. This case underscores the critical need for the identification and management of behavioral concerns in pediatric patients exhibiting similar clinical presentations.

DISCUSSION

The patient exhibited symptoms such as epigastric pain, nausea, and vomiting, in addition to a medical history of Attention Deficit Hyperactivity Disorder (ADHD) and pica-like behaviors. Diagnostic imaging confirmed the presence of a large trichobezoar, leading to the necessity of an exploratory laparotomy for its surgical removal. This case highlights the crucial role of comprehensive clinical assessment and imaging in the diagnosis of trichobezoars, especially in children with behavioral concerns. Managing such cases typically involves a multidisciplinary approach that combines surgical procedures with psychiatric assessment and behavioral therapy to reduce the likelihood of recurrence.

CONCLUSION

This case underscores the importance of considering trichobezoars in the list of potential diagnoses for pediatric patients exhibiting gastrointestinal symptoms, particularly in individuals with psychiatric or neurodevelopmental histories. Timely identification and management are crucial in averting serious complications linked to trichobezoars. The favorable surgical result in this particular patient underscores the significance of holistic care that attends to both the physical and psychological dimensions of the condition, ultimately enhancing the long-term outlook. Additional research is required to explore the relationship between underlying psychiatric conditions, particularly ADHD, and the formation of trichobezoars. Furthermore, novel therapeutic strategies need to be developed.

Gastric and Rectal Phytobezoar From Sunflower Seed Ingestion: A Case Report and Review of the Literature

Seed bezoars are a subcategory of phytobezoars caused by undigested vegetable seeds or fruit pits. We report the case of a 48-year-old woman who was admitted due to severe constipation and rectal pain. Rectal examination was notable for numerous sunflower seeds at the anal verge. Initial CT imaging revealed fecal impaction with a rectal bezoar which was managed with manual evacuation. Repeat CT imaging was notable for a gastric bezoar which was successfully managed by dissolution therapy with Coca-Cola. Most seed bezoars can be managed conservatively and life-threatening complications are rare.

Swallowed secrets - Plastic bezoar-induced gastric outlet obstruction in a 14-year-old girl: A case report

INTRODUCTION

Gastric outlet obstruction (GOO) is a rare but serious condition that can arise from various etiologies, including foreign body ingestion. We present a unique case of GOO in a 14-year-old girl resulting from the accumulation of plastic materials, known as a plastic bezoar, due to pica behavior.

CASE PRESENTATION

A 14-year-old girl with a history of pica presented with symptoms suggestive of acute gastric obstruction. Imaging studies revealed the presence of a large foreign body extending from the stomach to the jejunum, consistent with a plastic bezoar. Despite attempts at endoscopic removal, surgical intervention was ultimately required due to the size and location of the bezoar.

DISCUSSION

This case underscores the challenges associated with diagnosing and managing gastric outlet obstruction secondary to plastic bezoar formation, particularly in pediatric patients with underlying pica behavior. The diagnostic workup involved a multidisciplinary approach, including imaging studies and endoscopic evaluation. Surgical intervention, although invasive, proved necessary for definitive treatment in this case. Postoperative care focused on monitoring for complications and addressing the underlying pica behavior through psychological intervention and support.

CONCLUSION

This case highlights the importance of early recognition, thorough diagnostic evaluation, and prompt intervention to prevent complications and ensure favorable outcomes. Collaborative efforts between medical and surgical teams are essential for the comprehensive management of such cases, emphasizing the need for tailored approaches to address both the physical and psychological aspects of care.

Gastric Bezoars: A Retrospective Analysis of 44 Cases

BACKGROUND Gastric bezoars are a relatively rare condition. We aim to summarize the clinical characteristics and endoscopic features of patients with gastric bezoars, and analyze the treatment process. MATERIAL AND METHODS The medical records of 44 patients with gastric bezoars treated at Henan Provincial People's Hospital from September 2017 to December 2023 were retrospectively reviewed. RESULTS Among the 44 patients, there were 20 males and 24 females. The average age was 55.36±15.17 years. Abdominal pain was the primary symptom in patients with gastric bezoars. Single gastric bezoars were more common than multiple ones, accounting for 86.4% of all cases. Endoscopic examination revealed ulcers in 36 (81.8%) patients, mainly at the gastric angle and antrum. Single ulcers were more common than multiple ulcers, with most ulcer diameters being less than 2 cm. The occurrence of ulcers was not significantly related to patient age or the size of the bezoars. Endoscopic examination confirmed complete clearance of gastric bezoars in 30 patients. In the 26 patients treated successfully under endoscopy, the number of endoscopic treatments ranged from 1 to 4, with an average of 1.27 interventions per patient. The interval for the second endoscopic re-examination ranged from 2 to 6 days, with an average of 3.87±1.22 days. CONCLUSIONS The most common type of gastric bezoar is phytobezoars. There is a close association between ulcer formation and gastric bezoars. Endoscopic therapy combined with oral treatment can effectively treat gastric bezoars. Most patients require only 1 endoscopic treatment to be successful. The appropriate interval for a follow-up endoscopy after the first endoscopic treatment is around 4 days.

Peanut phytobezoar: an unusual cause for small bowel obstruction

Bezoars are indigestible masses of material forming within the gastrointestinal system. Phytobezoars are the most common subtype consisting of plant matter such as fibre, skins, and seeds. Rarely they present causing small bowel obstruction (SBO) and may be difficult to distinguish from faecalization on imaging. Here we present the case of a man in his 70s who rapidly consumed an expiring bag of peanuts and subsequently developed a SBO due to formation of a peanut phytobezoar. After failing conservative management, he required emergency surgery with intentional enterotomy to milk out the bezoar. This case highlights the importance of maintaining a broad differential and thorough history taking in patients presenting with SBO.

A Rare Case of Gastric Phytobezoar (Diospyrobezoar) in a Healthy Adult

Phytobezoars are solid masses of indigestible plant material and are a common type of gastrointestinal bezoar, with varying incidences globally. These bezoars typically form from the ingestion of high-fiber fruits and vegetables and are associated with factors such as decreased gastric acid production and delayed gastric emptying. We present a case of a 35-year-old healthy man with recurrent upper abdominal pain, nausea, a rolling ball sensation in the abdominal region, and a history of consuming unripe persimmons. Imaging revealed the presence of phytobezoars in the stomach, leading to unsuccessful endoscopic attempts at removal. Laparoscopic extraction was eventually performed successfully after failed conservative management. The case highlights the rarity of diospyrobezoars, a subtype of phytobezoars formed from persimmon ingestion, and the challenges in their management. Surgical intervention, particularly laparoscopic extraction, can be effective but carries risks such as surgical site infections. Comprehensive care involving diagnostic imaging, non-surgical interventions, and surgical techniques is crucial for the successful management of phytobezoars. Phytobezoars, though relatively common, present unique diagnostic and management challenges, especially when formed from specific dietary factors such as persimmons. Understanding their epidemiology, clinical manifestations, and treatment options, including the role of laparoscopic surgery, is essential for optimizing patient outcomes and minimizing complications such as surgical site infections.

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.

Health effects of microplastics and nanoplastics: review of published case reports

Microplastics and nanoplastics (MNPs) represent a pervasive environmental pollutant, raising significant concerns about potential health effects on humans. These tiny plastic particles have been detected across various environmental matrices, including air, water, soil, and food sources. While the adverse impacts of MNPs on wildlife and ecosystems are well-documented, understanding their effects on human health is still in its infancy. This study aims to comprehensively review existing case reports documenting adverse health outcomes associated with MNPs exposure. Through an extensive literature search, relevant articles were identified and analyzed. MNPs exposure primarily occurs through ingestion and inhalation routes. Health effects on the digestive system include oxidative stress, inflammation, dysbiosis, and metabolic disorders, with cases linking MNPs exposure to gastrointestinal injury and liver dysfunction. Respiratory system impacts include asthma exacerbation and hypersensitivity pneumonitis, particularly in industries involving plastic production. MNPs exposure has also been associated with nervous system conditions, reproductive toxicity, skeletal system interference, excretory system disruption, and cardiovascular morbidity and mortality. Despite limited case reports, the widespread presence of MNPs warrants further investigation into their potential health risks. This study underscores the urgency of understanding and mitigating the adverse health effects posed by MNPs exposure. Further research is imperative in order to comprehensively assess and address the dangers associated with MNPs contamination in the environment.

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.

Trichobezoar effectively treated with direct endoscopic injection of Coca-Cola: A case report

Trichobezoars (hair bezoars) are primarily observed in adolescent girls who pull their hair followed by its ingestion. Endoscopic removal of trichobezoars is challenging, and these masses often require surgical removal. Recently, although it has been reported that Coca-Cola could effectively dissolve persimmon phytobezoars, it was ineffective in dissolving trichobezoars. We report a case in which Coca-Cola was directly injected into a trichobezoar followed by successful endoscopic removal of the mass. A 9-year-old girl visited our hospital with abdominal pain and nausea, wherein abdominal radiography revealed a mass in the stomach. Her mother witnessed her pulling and ingesting her hair 6 months previously. An upper endoscopy was performed for diagnosis of the trichobezoar. Endoscopic removal of the mass was performed under general anesthesia following oral administration of Coca-Cola at a dose of 100 mL thrice a day for 10 days. Initially, we attempted endoscopic extraction using grasping forceps and a radiofrequency snare. However, the bezoar could not be fragmented and did not pass through the cardia. Thus, Coca-Cola was injected directly into the bezoar using a local injection needle, which facilitated the separation of the bezoar and allowed the grasping forceps to fragment it to a size that could pass through the cardia. Owing to the large size of the bezoar, we could remove 180 g of it without complications. The patient received psychological counseling after the procedure, to prevent recurrence. In conclusion, direct injection of Coca-Cola was effective in the complete endoscopic removal of trichobezoars.

Coca-Cola consumption vs fragmentation in the management of patients with phytobezoars: A prospective randomized controlled trial

BACKGROUND

Gastric phytobezoars (GPBs) are very common in northern China. Combined therapy involving carbonated beverage consumption and endoscopic lithotripsy has been shown to be effective and safe. Existing studies on this subject are often case reports highlighting the successful dissolution of phytobezoars through Coca-Cola consumption. Consequently, large-scale prospective investigations in this domain remain scarce. Therefore, we conducted a randomized controlled trial to examine the effects of Coca-Cola consumption on GPBs.

AIM

To evaluate the impact of Coca-Cola on GPBs, including the dissolution rate, medical expenses, ulcer rate, and operation time.

METHODS

A total of 160 consecutive patients diagnosed with GPBs were allocated into two groups (a control group and an intervention group) through computer-generated randomization. Patients in the intervention group received a Coca-Cola-based regimen (Coca-Cola 2000-4000 mL per day for 7 d), while those in the control group underwent emergency fragmentation.

RESULTS

Complete dissolution of GPBs was achieved in 100% of the patients in the intervention group. The disparity in expenses between the control group and intervention group (t = 25.791, P = 0.000) was statistically significant, and the difference in gastric ulcer occurrence between the control group and intervention group (χ2 = 6.181, P = 0.013) was also statistically significant.

CONCLUSION

Timely ingestion of Coca-Cola yields significant benefits, including a complete dissolution rate of 100%, a low incidence of gastric ulcers, no need for fragmentation and reduced expenses.

Small bowel obstruction caused by dehydrated apple ingestion: the challenges of preoperative radiological diagnosis and surgical management

A man in his 60s with a virgin abdomen presented with sudden-onset generalised abdominal pain and fevers. The night prior, he snacked on supermarket purchased dehydrated apples. CT abdomen and pelvis revealed small bowel obstruction (SBO) to the mid ileum and small amount of free fluid within the pelvis. The patient underwent emergency exploratory laparotomy. High-grade SBO was identified, caused by large obstructing phytobezoars, with three further proximal large phytobezoars identified. All four phytobezoars were extracted and found to be rehydrated pieces of dehydrated apple that had increased in size in the gastrointestinal tract. The patient was later found to have further phytobezoars in the stomach which passed conservatively. The patient recovered well. This case demonstrates the challenges of preoperative radiological diagnosis in phytobezoar-related SBO and the significance of enterotomy orientation and closure to ensure a safe repair to withstand the passage of any residual rehydrating phytobezoars.

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.

Small bowel obstruction due to a meat bolus bezoar: the second case report in literature

Introduction

Small bowel obstruction is a difficult emergency condition that may be caused due to many factors. However, bezoar-induced small bowel obstruction accounts for only 0.4-4.8% of all intestinal impaction patients. Bezoars are an entity of undigested materials classified into four types: phytobezoar, trichobezoar, pharmacobezoar, lactobezoar. Meat bolus bezoar is not named under any of these classifications.

Case presentation

A 75-year-old man presented with abdominal distention, vomiting, and constipation. On radiological imaging, a mass in the terminal ileum was detected. After 2 days of ineffective conservative therapy, the authors decided to perform an open surgery. Enterotomy approach was chosen after failing to milk the object into the colons. The foreign body impacting the bowels was identified as a meat bolus bezoar. The patient improved after the surgery. The authors recorded no recurrence or complications with our patient after 18 months of follow-up.

Discussion

Patients with small bowel obstruction usually present with acute abdominal pain and distension despite the blockage cause. Computed tomography is the most effective diagnostic tool in such cases. In bezoar-induced intestinal blockage, surgical management is mandatory if conservative therapy fails.

Conclusion

It is important to consider bezoar-induced small bowel obstruction as a potential cause of impaction in cases of acute abdominal pain accompanied with risk factors of bezoar formation, despite the bezoar type.

Pharmacobezoar-Related Fatalities: A Case Report and a Review of the Literature

ABSTRACT

Pharmacobezoars develop after an acute overdose or during routine drug administration. Here, the authors present a case of fatal multidrug overdose involving a 62-year-old woman. Her usual treatment included tramadol extended-release, citalopram, and mirtazapine. Furthermore, she self-medicated and misused her husband's medications. The autopsy revealed the presence of a voluminous medication bezoar in the stomach. No mechanical complication was noted. Toxicologic analyses were performed using gas chromatography with flame ionization detection, liquid chromatography with diode array detection, gas chromatography with mass spectrometry detection, and liquid chromatography coupled to tandem mass spectrometry. Tramadol (34,000 mcg/L), O-desmethyltramadol (2200 mcg/L), propranolol (6000 mcg/L), bromazepam (2500 mcg/L), zopiclone (1200 mcg/L), and citalopram (700 mcg/L) were identified in femoral blood at toxic concentrations. Interestingly, the femoral blood and vitreous humor concentration ratio was approximately 0.7. Furthermore, an English exhaustive literature search was performed using several different electronic databases without any limiting period to identify published pharmacobezoar-related fatalities. Seventeen publications were identified reporting a total of 19 cases. Decedents' mean age was 47.6 years [0.8-79] and a clear female predominance emerged. Several drugs were involved in pharmacobezoar formation. Death was attributed to drug toxicity in 13 cases, and to mechanical complications and/or sepsis in 4 cases. A mixed cause of death was reported in 2 cases. Although rare, pharmacobezoars remain potentially lethal and raise challenges in therapeutic management.

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.

Age-specific causes of upper gastrointestinal bleeding in children

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

Bezoars: Culprits of gastrointestinal obstruction that may lead to surgical intervention and potentially surgical complications

Key Clinical Message

Bezoars can cause gastrointestinal obstruction and may require surgery. Surgery carries the risk of complications. Medical professionals should perform detailed history in diet and behaviors for patients presenting with abdominal pain to identify risk factors for bezoars, then educate these patients and their families about risks and complications of bezoars.

Abstract

Bezoars are solid masses of undigested material that can cause obstruction of the gastrointestinal tract. There are different types of bezoars; phytobezoar, trichobezoar, pharmacobezoar, lactobezoar, and bezoars containing tissue paper or polystyrene foam. This case report is of a 13-year-old Hispanic male who suffered a postsurgical complication after removal of bezoar. He had a past surgical history of appendectomy and presented to the hospital with a 1-day history of right lower quadrant abdominal pain associated with fever and diarrhea. X-radiation images and computed tomography scans aided in the diagnosis of pelvic abscess as a complication of postsurgical enterotomy and closure of the enterotomy to remove bezoar from the small bowel. The initial bezoar removal and the postsurgical complication of pelvic abscess resulted in the patient staying for 19 days in the hospital. At discharge, the patient and his guardian were advised to follow up with the patient's primary care physician and surgical team. The patient made an uneventful recovery. He did not experience any long-term complications and fully recovered. This report demonstrates that although bezoars are rare, they can cause significant obstruction of the gastrointestinal tract leading to the need for management, such as surgery, which carries its own risks. It is important to note that the postsurgical complication of pelvic abscess can occur due to surgery itself and not because of bezoar specifically. Abdominal surgery in general poses the risk of pelvic abscess. The consideration is to expectantly decrease the occurrence of bezoars so that consequently there will not be a need for surgery in removal of bezoars due to obstruction. The effects of bezoars can be prevented through educating the community and addressing underlying psychiatric disorders.

Revisional Bariatric Surgery due to Complications: Indications and Outcomes

BACKGROUND

The increasing prevalence of bariatric procedures has led to a surge in revisional surgeries. Failure of bariatric surgery can be attributed to inadequate weight loss or complications necessitating revisional surgery. In this study, we investigated the indications and outcomes of revisional surgery due to complications following primary bariatric surgery.

MATERIALS AND METHODS

A retrospective study was conducted using data from the Tehran Obesity Treatment Study, which included patients who underwent revisional bariatric surgery between March 2013 and September 2021 due to complications following primary bariatric surgery.

RESULTS

Of the 5382 patients who underwent primary bariatric surgery (sleeve gastrectomy, one-anastomosis gastric bypass, and Roux-en-Y gastric bypass), 203 (3.70%) required revisional surgery, with 37 cases performed due to surgical complications. The indications of revisional operations were gastroesophageal reflux disease (GERD) (n=17, 45.9%), protein-calorie malnutrition (PCM) (n=14, 37.8%), unexplained abdominal pain (n=5, 13.5%), and phytobezoar (n=1, 0.03%). In the postoperative follow-up, most patients exhibited improvement in signs and symptoms related to underlying causes. However, eight patients experienced early or late complications of grade III or higher according to the Clavien-Dindo classification, with one death resulting from liver failure.

CONCLUSION

Revisional bariatric surgery may effectively address complications from primary bariatric surgery, with the majority of patients experiencing improvements in symptoms. While the overall incidence of revisional surgery due to complications is relatively low, our findings suggest that GERD and PCM are the most common indications for revisional surgery.

A rare cause of intestinal obstruction in children trichobezoar: How to diagnose?

BACKGROUND

Trichobezoar is a rare clinical condition in children, which is caused by the accumulation of swallowed hair mass in the digestive tract. This condition is most common in young women with psychiatric histories who suffer from trichotillomania (TTM), where they have an irresistible urge to pull out their hair. Diagnosis and treatment of this pathology, which is already extremely rare, and its variable clinical presentations are challenging. The aim of this study was to increase awareness of trichobezoar in the differential diagnosis of signs of intestinal obstruction in children and to evaluate the diagnosis and management of this rare pathology.

METHODS

The clinical data of six patients who were treated for trichobezoars in the pediatric surgery department of our hospital between 2009 and 2022 were retrospectively analyzed.

RESULTS

Six female patients were treated with the diagnosis of trichobezoar during this period. Patients were diagnosed with the help of anamnesis, physical examination, abdominal ultrasonography (USG), and finally, endoscopy. USG can predict the intestinal wall infiltration and the tail extended to the duodenum through pylorus in the series. All patients were evaluated with contrast-enhanced abdominal radiography. Five surgical interventions were performed in four of the cases. In a case who underwent surgery twice, the distal intestinal satellite bezoar was not noticed in the first operation. Two patients were diagnosed to have trichobezoar, but surgery was not required. These patients were younger and had early-onset TTM (before 10 years old). The patients were followed for an average of 10.8 years and no recurrence was detected.

CONCLUSION

Trichobezoar is a rare cause of intestinal obstruction in children with fatal complications when diagnosed late. Failure to follow an algorithm for the management of the disease causes difficulties in the diagnosis and treatment. Especially in pa-tients with a known psychiatric history, whole abdominal USG and laparoscopy performed with awareness can prevent unnecessary examinations.

Intestinal Obstruction Due to Reassembly after Endoscopic Crushing of a Bezoar

An 87-year-old woman visited her primary-care doctor because of nausea and epigastric pain. Esophagogastroduodenoscopy (EGD) revealed a giant bezoar in her stomach. She was referred to our hospital after carbonated beverage dissolution proved ineffective and underwent endoscopic mechanical crushing. After crushing, the symptoms disappeared, and she began eating. Later, however, the crushed fragments reassembled in the duodenal bulb and caused intestinal obstruction. The patient underwent emergency EGD for crushing once more, and all of the fragments were extracted from the body. This case highlights the need for bezoars to be removed from the body after crushing in order to avoid reassembly.

Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy

A male patient in his 30s, with myotonic dystrophy (DM), presented to the emergency department with abdominal pain and vomiting. CT imaging revealed a soft tissue lesion in the terminal ileum causing small bowel obstruction (SBO). The patient underwent diagnostic laparoscopy which allowed identification and removal of the obstructing lesion. This was in the form of an intact, undigested potato, a phytobezoar. Bezoars are collections of undigested material found in the gastrointestinal (GI) tract, a phytobezoar is composed of plant material and is the most common form of bezoar. DM is a multisystem disorder characterised by skeletal muscle weakness, however it often presents with GI symptoms and the muscles of mastication are often affected. DM is a known risk factor for bezoar formation and should be considered as an important differential in DM patients presenting with SBO.

Laparoscopic management of rare smoked dry pork bezoar in the stomach

Medical literature recognise only 4 types of bezoar - phytobezoar, trichobezoar, lactobezoar and pharmacobezoar. Here, we discuss a new unique type of bezoar composed of undigested dry pork. A 58-year-old male patient from Nagaland, India, presented with intermittent symptoms of gastric outlet obstruction and pain abdomen. On clinical examination, he was found to have an epigastric lump. Upper gastrointestinal endoscopy showed an undigested ball of swallowed meat at the pylorus and later at the fundus on repeat endoscopy just before the surgical intervention. Endoscopic mechanical fragmentation was tried, but owing to the large size and hard sticky consistency of the bezoar, fragmentation was not feasible. Due to persistent pain abdomen and clinical gastric outlet obstruction, a decision for operative intervention was taken. He finally underwent laparoscopic anterior gastrotomy and evacuation of the bezoar. The post-operative course was uneventful, and the patient went home symptom free on the 5th post-operative day.

Gastrointestinal bezoars: Review of the literature and report of a rare case of pumpkin seed rectal impaction

In science, bezoar is a mass of hair or undigested vegetable matter, found in a human or animal's intestines, similar to a hairball. Usually, it is found trapped in every part of the gastrointestinal system and must be distinguished by pseudobezoar which is an indigestive object voluntarily introduced into the digestive tract. The term Bezoar is from Arabic bāzahr, "bezoar" or ultimately from Middle Persian p'tzhl pādzahr, "antidote, bezoar"ægagropile o egagropile It should be a universal antidote that works against any poison, and could neutralize any poison. Otherwise, the name could derive from a kind of Turkish goat whose name is just bezoar. Authors report a case of fecal impaction by pumpkin seeds bezoar with abdominal pain: a difficulty to void with subsequent rectal inflammation and hemorrhoid enlargement was observed. The patient underwent a successful manual disimpaction. Guidelines do not require IRB approval Authors examined the literature about occlusion from bezoar The most common causes of occlusion from bezoar are: a previous gastric surgery such as a gastric band (for weight loss) or gastric bypass, a reduced stomach acid (hypochlorhydria) or decreased stomach size, a delayed gastric emptying, typically due to diabetes, autoimmune disorders, or mixed connective tissue disease. Seed bezoars are usually found in the rectum of patients without predisposing factors, causing constipation and pain. Rectal impaction is common after ingestion of seeds while a true occlusion is rare. Although several cases of phytobezoars composed of various types of seeds are reported in literature, bezoars of pumpkin seeds have rarely been reported.

Successful Dissolution of a Large Gastric Phytobezoar Through Nonsurgical and Nonendoscopic Fragmentation

A phytobezoar is the result of poorly digestible vegetable matter that accumulates in the gastrointestinal tract often forming a hard mass in the stomach. We present a case of a phytobezoar in a patient without predisposing risk factors, resulting in significant stomach distension initially believed to require high-risk surgical intervention but which ultimately resolved after 3 days of conservative treatment with prokinetic agents. The patient was discharged uneventfully and was recommended a low-fiber diet indefinitely while undergoing further workup for motility disorders.

Large Sigmoid Fecaloma: A Rare Case of a Common Condition in Patients With Parkinson's Disease

A fecaloma is a rare complication of chronic constipation that is more commonly seen in elderly individuals with chronic neuropsychiatric disorders. We present the case of a 79-year-old patient with Parkinson's disease with refractory constipation due to a large fecaloma mass in the sigmoid colon, which is a rare sequela of poorly managed chronic constipation. The current report highlights the importance of aggressive medical therapy for chronic constipation in this group of patients to prevent life-threatening complications.

Small Bowel Obstruction by a Phytobezoar in a Patient With Previous Antrectomy and Billroth II Reconstruction

A phytobezoar is a conglomerate of improperly digested fruit and vegetable debris, and its development is associated, amongst other factors, with previous gastric surgery. Most phytobezoars remain asymptomatic and are incidentally found during imaging or interventional procedures. However, in some patients, they can cause small bowel obstruction, which can subsequently lead to severe complications. Although the clinical findings are similar to other causes of intestinal obstruction, there are some particular diagnostic and treatment features more specific to phytobezoars. We present a case of an 85-year-old man with a history of previous antrectomy and Billroth II reconstruction who came to the emergency department with bilateral aspiration pneumonia and intestinal obstruction due to a bezoar. The CT scan showed bilateral inferior lobe pulmonary consolidation, as well as a marked dilation of the small bowel with gas-fluid levels and a transition to normal caliber in the terminal ileum, where an oval mottled-appearing mass suggesting a bezoar was present. An urgent laparotomy confirmed the diagnosis, and an enterotomy with removal of the bezoar was performed. Phytobezoars must be considered as a cause of intestinal obstruction, particularly when patients have a history of previous gastric surgery. Its radiological findings, particularly in CT scans, are specific and should be appreciated to establish the diagnosis promptly. The treatment of small bowel obstruction due to a phytobezoar requires surgery most of the time, and the surgeon must bear in mind the need to look for the existence of other bezoars in the gastrointestinal tract to prevent reoccurrence.

Meat bezoar due to inadequate mastication leading partial bowel obstruction: A case report

INTRODUCTION

Gastrointestinal bezoars may occur in individuals with a normal gastrointestinal tract structure or as a result of gastrointestinal defects and disease. This rare condition initially presents with general abdominal pain, mimicking appendicitis in later stages. Recognizing this condition as a differential diagnosis in patients with abdominal pain can prevent delays in diagnosis and serious complications.

PRESENTATION OF CASE

We report a rare case of a meat bezoar in a 52-year-old man presenting with acute and generalized abdominal pain at an emergency department.

DISCUSSION

We discuss gastrointestinal bezoars as a rare differential diagnosis of abdominal pain and acute abdomen in people with no pre-existing medical history, and the challenges that might be faced during diagnosis and treatment.

CONCLUSION

Gastrointestinal bezoars are rare which makes the diagnosis challenging. Obtaining a complete history and a full examination with appropriate imaging could help the diagnosis.