Gastric Bezoar: Retrieve it, Leave it, or Disbelieve it?

Abstract

Objectives: 

To determine the demographics, potential risk factors, endoscopic interventions and outcomes relating to gastric bezoars in pediatric patients; and comparing results with previously published literature.

Methods: 

Retrospective series by chart review of patients identified by International Classification of Diseases-9 codes 938 and 935, using the following Medical Subject Headings: 1, term bezoar; 2, Keywords gastric bezoar^∗ or gastric foreign body^∗.

Results: 

Thirty pediatric patients between ages of 2 to 18 years were found with gastric bezoars, with a female predominance. Majority had a phytobezoar. Six patients were diagnosed with dysautonomia, implying possible role of autonomic dysfunction contributing to abnormal gastric retention. Frequent symptoms included abdominal pain, nausea and vomiting, a decrease in appetite, and unintentional weight loss. A higher prevalence of underlying gastrointestinal disorders was found in those with bezoars. Nuclear medicine gastric emptying scan performed in 13 children was significantly abnormal in only 4 of these children. Most patients were treated with endoscopic removal of the bezoar. Endoscopic removal was accomplished by Roth net, generally requiring multiple passes. At follow-up, most of the children had improvement of symptoms, with bezoar recurrence in 1 patient.

Conclusions: 

This is to our knowledge the largest series of gastric bezoars in pediatrics. On the basis of our review, phytobezoars may be under-reported in pediatrics. Bezoars should be considered in children presenting with chronic abdominal pain, nausea, and vomiting; even in developmentally normal children and those with normal gastric emptying. We suggest that dysautonomia and underlying gastrointestinal disorders may be potential risk factors.

What Is Known

• Bezoar is a mass found trapped in the gastrointestinal system.
• Tricobezoars (masses of retained hair) have been reported more often in paediatrics.
• Bezoars have often been reported in developmentally delayed or institutionalized children.

What Is New

• Information on incidence, demographics, and potential risk factors.
• There is debate on management strategies, including endoscopic interventions, although the authors favor removal. An algorithm has been proposed to guide management.
• Outcomes and prognosis are discussed. Most of the children who had their bezoars removed did well.

A bezoar is defined as a mass found trapped in the gastrointestinal system (usually the stomach, occasionally the rectum) ^(1,2). The term bezoar comes from the Persian word badzehr, which refers to the material found in sacrificed animals, such as goats ^(1–3). In ancient times, this material was thought to have magical or medicinal powers and was used as an antidote to poisons from snake bites, infections, diverse diseases, and even as a means of combating aging. The overall incidence of bezoars in pediatrics is unknown; a 10-year study at a community hospital found a total of 18 adults with bezoars admitted between 1992 to 2002, estimating a rate of 0.0125% of hospitalizations, or a prevalence of 0.6 : 100,000 per year ⁽⁴⁾, whereas another study in Romania from 1992 to 2011 revealed 49 cases over a span of 20 years (0.068% from all endoscopies) ⁽⁵⁾.

Common types include phytobezoars composed of vegetable matter, trichobezoars composed of swallowed hair, lactobezoars composed of milk protein and pharmacobezoars composed of undissolved medication ^(6–8). A bezoar in the esophagus or upper gastrointestinal tract is sometimes reported in developmentally delayed or institutionalized children ^(2,9). Although the majority of bezoars are found in the stomach, bezoars can sometimes migrate into the small intestine. Yakan et al ⁽¹⁰⁾ reviewed 432 cases of small bowel obstruction treated within 10 years of which 14 cases (3.2%) were caused by phytobezoars. In a meta-analysis by Ghosheh and Salameh ⁽¹¹⁾ reviewing 19 reported studies published from 1994 to 2005, laparoscopy was attempted in 1061 patients presenting with acute small bowel obstruction, and bezoars represented the fifth most common cause, accounting for 0.8%.

We have identified 30 pediatric patients diagnosed with gastric bezoar during a span of 11 years (2008–2019) at the University of Texas Health Sciences Center/Children's Memorial Hermann Hospital, Houston. We performed a retrospective case analysis to see how our findings compare to the pediatric literature relating to the occurrence of bezoars, which are thought to be relatively rare causes of vomiting and abdominal pain in children.

METHODS

This is a retrospective case series by chart review of patients identified by International Classification of Diseases-9 codes 938 and 935. We used the following Medical Subject Headings: 1, MeSH terms bezoar; 2, Keywords gastric bezoar∗ or gastric foreign body∗, and searched Pubmed, MEDLINE OVID, and Texas Medical Center library resources data.

RESULTS

We identified 30 pediatric patients with gastric bezoar over 11 years from 2008 to 2019 at the University of Texas Health Sciences Center/Children's Memorial Hermann Hospital, Houston (Table 1). The children ranged from ages 2 to 18; all but 3 were older than 6, with a mean age of 11.6. The female : male ratio was 17 : 13, and 56% were Caucasians, 31% were African-Americans, and 13% were Hispanic. Fifteen children had a normal body mass index for age, whereas 11 had a body mass index <5 percentile and 4 had a body mass index >95 percentile. There was a high prevalence of underlying gastrointestinal disorders in those with bezoars: 4 patients had eosinophilic esophagitis and/or duodenitis, 4 had celiac disease, 3 had been diagnosed with irritable bowel syndrome, and 3 met criteria for cyclic vomiting syndrome. Only 1 patient had a trichobezoar; all the rest were phytobezoars (Fig. 1). Six (20%) carried the diagnosis of dysautonomia, which had been confirmed by tilt table testing, implying possible role of autonomic dysfunction contributing to abnormal gastric retention (Table 2). Frequent symptoms included abdominal pain (60%), nausea and vomiting (50%), a decrease in appetite (32%), and unintentional weight loss (25%) (Table 2). Nine of the 30 patients were on acid blocker medication before presentation.

TABLE 1 - Patient demographics and underlying disorders

No.	Age, years	Sex	Ethnicity	BMI%	Underlying disorder(s)
1.	15	Male	Caucasian	19	Irritable bowel syndrome, insomnia
2.	12	Female	African American	13	Sickle cell anemia
3.	18	Female	Caucasian	23	Headaches, hypertension
4.	10	Male	Caucasian	14	None
5.	8	Female	Hispanic	21	None
6.	17	Male	Caucasian	54	Cyclic vomiting syndrome, dysautonomia, obesity, eosinophilic duodenitis, gastritis, and gastric polyps
7.	8	Male	African American	31	Autism spectrum disorder, G tube dependent
8.	15	Female	Caucasian	24	Mitochondrial disorder, G tube dependent
9.	7	Female	Caucasian	24	Constipation
10.	17	Female	Caucasian	22	Tylenol ingestion
11.	18	Female	Caucasian	27	Neurocardiogenic syncope with dysautonomia
12.	17	Female	Caucasian	20.5	Ehler-Danlos syndrome, dysautonomia, peptic ulcers, gastroparesis, migraine, G tube dependent
13.	6	Female	Hispanic	14	Gastroschisis, intestinal perforation at birth, liver cirrhosis, portal hypertension, developmental delay, failure to thrive
14.	4	Male	African American	15	None
15.	17	Female	Caucasian	28	Charcot-Marie-Tooth syndrome, mitochondrial disease, spinal muscle atrophy, asthma and dysautonomia
16.	12	Female	Caucasian	13	VATER syndrome, imperforate anus, mitochondrial disorder, cyclic vomiting syndrome, diastomatomyelia
17.	15	Male	Caucasian	16.8	Eosinophilic duodenal ulcer, eosinophilic esophagitis
18.	15	Female	African American	18	Irritable bowel syndrome with diarrhea
19.	2.5	Female	African American	15	Asthma
20.	16	Female	Caucasian	18	Dysautonomia, gastroparesis
21.	2	Male	Hispanic	14	Failure to thrive, cyclic vomiting
22.	11	Male	African American	20	Renal insufficiency, hypothyroidism, panhypopituitarism
23.	16	Female	Caucasian	18	Celiac disease
24.	12	Male	Hispanic	19	Persistent, severe iron deficiency anemia
25.	12	Female	Caucasian	18	Celiac disease
26.	6	Female	African American	17	Eosinophilic esophagitis, asthma, eczema
27.	15	Male	Caucasian	24	Autism, gastroesophageal reflux disease despite fundoplication, constipation
28.	2	Male	African American	17	Reactive airways disease, allergic rhinitis
29.	8	Male	African American	15	Ex-24-week premature infant, autism, gastroesophageal reflux despite Nissen fundoplication, constipation, Pica, gastrostomy dependence, chronic lung disease
30.	17	Male	Caucasian	19	Irritable bowel syndrome

BMI = body mass index.

FIGURE 1: Fifteen-year-old boy with history of irritable bowel syndrome who underwent an upper endoscopy for complaints of abdominal pain and diarrhea. As seen above, a phytobezoar was noted in body of stomach and bezoar was removed with Roth net and suction.

TABLE 2 - Presenting symptoms, type of bezoar, number of passes required, technique of removal, and follow-up responses

No.	Presenting symptoms	Type of bezoar	Number of passes	Technique of removal	Follow-up responses
1.	Abdominal pain, diarrhea	Phytobezoar	Not reported	Roth net and suction	Improvement in symptoms after multiple med changes
2.	Decreased oral intake, abdominal pain, weight loss, vomiting, palpable stomach mass	Trichobezoar	Not amenable to EGD removal	Ex-lap with gastrotomy and removal	Improvement in symptoms after removal with no recurrence
3.	Acid reflux, nausea, eroded dental enamel	Phytobezoar	15–20 times	Copious irrigation with 30 mL normal saline 15–20 times followed by suction	Improvement in symptoms after removal with no recurrence
4.	Poor oral intake, weight loss	Phytobezoar	Multiple passes	Retrieval basket via piecemeal removal	Resolution of symptoms after removal with weight gain
5.	Abdominal pain	Phytobezoar	Not removed	Not removed	Lost to follow-up
6.	Abdominal pain, vomiting	Phytobezoar	Not mentioned	Broken with saline flushes (75 mL) and then suctioned	Improvement in vomiting but persistent nausea
7.	Vomiting, abdominal pain, weight loss	Phytobezoar	Multiple passes	Retrieval basket via piecemeal removal	Improvement of symptoms and weight gain after removal with no recurrence
8.	Nausea, abdominal pain	Phytobezoar	Not mentioned	Suctioning	Persistence of dysphagia
9.	Abdominal pain	Phytobezoar	Not mentioned	Not mentioned	Improvement in symptoms without recurrence
10.	Abdominal pain, vomiting, nausea, weight loss	Phytobezoar	Multiple passes	Roth net	Resolution of symptoms after removal with weight gain
11.	Abdominal cramping, loss of appetite, nausea, vomiting	Phytobezoar	Multiple passes	Irrigation and suctioning	Did not follow-up
12.	Epigastric abdominal pain, bloating, decreased appetite, weight loss	Phytobezoar	Removed easily	Irrigation and suctioning	Transitioned to adult
13.	Melena, low hemoglobin, incidental finding of bezoar	Phytobezoar	Not removed, repeat EGD after 15 days showed resolution of bezoar	Not removed	Asymptomatic
14.	Vomiting	Phytobezoar	Unable to be removed endoscopically	Removed surgically via ex lap, gastrotomy and gastroplasty	Did not follow up
15.	Reflux, early satiety	Phytobezoars	Not removed	Not removed	Transitioned to adult
16.	Abdominal pain, vomiting	Large gastric phytobezoar x 2 (2014, 2017)	2014: multiple passes2017: 30 passes over 2.5 hours	2014: Snare and suctioning 2017: Roth net	No recurrence after second time removal of bezoar
17.	Abdominal cramping, loss of appetite, nausea, vomiting	Phytobezoar	2 passes	5 flushes of 50 mL normal saline, as well as 2 passes of Roth net.	Currently asymptomatic on elimination diet + formula feeds, s/p pyloroplasty and duodenoduodenostomy
18.	Abdominal pain, nausea	Phytobezoar	2 passes	Multiple water flushes to break bezoar followed by Roth net extraction	Control of abdominal pain on meds
19.	Chronic vomiting	Phytobezoar	1 pass	Suctioning and irrigation	Lost to follow-up
20.	Abdominal pain, loss of weight, dysphagia	Phytobezoar	1 pass	Suctioning and irrigation	Transitioned to adult
21.	Poor oral intake, weight loss	Phytobezoar	Not removed	Not removed	Currently with improved weight gain on supplemental nasogastric feeds and cyproheptadine
22.	Vomiting, gastric distension	Phytobezoar	Not mentioned	Suctioning and Roth net	Patient died soon after the procedure because of decompensated respiratory status
23.	Abdominal pain, diarrhea	Phytobezoar	5 passes	Suctioning and Roth net	Improvement in symptoms without recurrence
24.	Persistent, severe iron deficiency anemia	Phytobezoar	23 passes	Suctioning and Roth net	Iron deficiency anemia persists, no other symptoms
25.	Crampy abdominal pain	Phytobezoar	9 passes	Suctioning and Roth net	Awaiting follow up
26.	No gastrointestinal symptoms	Phytobezoar	Not mentioned	Suctioning and Roth net	Awaiting follow up
27.	Abdominal pain	Phytobezoar	2 passes	Suctioning and Roth net	Improvement in symptoms without recurrence
28.	Vomiting, weight loss	Large bezoar causing gastric outlet obstruction	6 passes, eventually required ex-lap with gastrostomy and gastroplasty	Initial extraction with Roth net, eventually required ex-lap with gastrostomy and gastroplasty	Lost to follow-up
29.	Decreased appetite, vomiting	Phytobezoar	Multiple passes	Roth net	Improvement in symptoms
30.	Chronic abdominal pain, nausea, vomiting, diarrhea	Phytobezoar	1 pass	Not mentioned	Some improvement in symptoms after bezoar removal and with current meds (euloxadoline and mirtazepine)

A nuclear medicine gastric emptying scan was performed in 13 children (Table 3). The study was normal in 5 subjects, with 4 showing mild delay and 4 others showing very abnormal gastric emptying.

TABLE 3 - Gastric emptying scan results

Patients with bezoars who had a gastric emptying scan
No.	T1/2, minutes	Lag phase	%90 minutes retention	%180 minutes retention	%240 minutes retention	Food type	Delay	Dumping	Abnormal score
1.	110		55	35	31	Solid	Yes		2
2.	64		35			Solid	No		0
3.	62		25			Solid	No		0
4.	38		0			Solid	No	Yes	1
5.	55		20			Semisolid	No		0
6.	90		60		0	Solid	No		0
7.	39		0			Solid	No		0
8.	55	45 minutes	10			Semisolid	No		1
9.	155	90 minutes	95	40	20	Semisolid	Yes		2
10.	140	>60 minutes	70	41	16	Solid	Yes		2
11.	110	90 minutes	95		30	Semisolid	Yes		2
12.	111		85	10		Solid	No		1
13.	60		10			Liquid	No		1

Normal T1/2 for solids is 90 minutes, semisolids is 60 minutes, and liquids is 45 minutes.Scoring system for the scan is as follows: 0 for normal scan. 1 for mild delay with mildly delayed T1/2 or prolonged lag phase or dumping. Late emptying is normal. 2 for definite delay with prolonged T1/2, prolonged late phase emptying, especially 4-hour retention >10%.

Most patients were treated with endoscopic removal of the bezoar; but 4 children required surgical intervention, with exploratory laparotomy and gastrotomy. Endoscopic removal was accomplished by Roth net, generally requiring multiple passes (6–20 passes) (Table 2). There was an 11-year-old child with seizure disorder and pan-hypopituitarism found face down in a bath tub in vomitus who developed severe distension while being bag ventilated during resuscitation. Intensivists could not place a nasogastric tube, and we were called to do endoscopy. We noted a large phytobezoar occluding the lower esophageal sphincter at endoscopy, which decompressed rapidly with passage of the endoscope. The boy was, however, found to have experienced brain death, the cause likely secondary to aspiration and severe gastric distention.

For the other children, at follow-up visits at 2 months +/− 15 days, most of the children had improvement of symptoms (n = 18), with bezoar recurrence in only 1 patient (Table 2).

DISCUSSION

This is to our knowledge the largest series of gastric bezoars in pediatrics. In an extensive review in 1938, Debakey and Ochsner presented a review of 303 published cases, adding 8 of their own, a series, which included both adults and children. Of those in their series, only 40% had phytobezoars, whereas most were trichobezoars ⁽¹²⁾. On the basis of our review, phytobezoars may be under-reported in pediatrics. Bezoar formation has been thought to be secondary to ingestion of nondigestible or slowly digested materials in the setting of delayed gastric emptying or impaired gastric motility ^(2–4,9), but this report demonstrates that additional factors may also be involved in those with normal or even accelerated gastric emptying. Bezoars should be considered in children presenting with chronic abdominal pain, nausea, and vomiting, even in developmentally normal children and those with normal gastric emptying. We suggest that dysautonomia and underlying gastrointestinal (GI) disorders may be potential risk factors.

Treatment options described for bezoars are based on the type and the size of the bezoar, with the larger ones posing a more difficult challenge. For example, persimmon phytobezoars, which compared with other bezoars are more difficult to dissolve or break up into small pieces because of their hard consistency. The currently available management strategies for a gastric phytobezoar include dissolution of the bezoar by cola beverages, removal by endoscopic devices, laparotomy, and laparoscopic surgery ^(13–15). A recent review by Ladas et al summarized 24 publications including 46 patients and noted that Coca-Cola administration resulted in phytobezoar resolution in 91% of the cases, either as a sole treatment or in combination with an endoscopic procedure. The protocol has varied depending on authors; both nasogastric and oral administration of cola has been used. In addition, other methods to dissolve bezoars have been used including water, papain, and other digestive enzymes containing cellulose ^(13–15).

Although unproven by a placebo-controlled trial, we suggest that bezoar-associated symptoms will often improve with endoscopic removal. The technique of endoscopic removal is provider-dependent; in addition to irrigation and Roth net, using a metal snare to break up bezoar is another technique that has been used. We must, however, acknowledge that there is no consensus about what should be done, even amongst the pediatric gastroenterologists in our group. When a large gray-white accumulation of material is found in the stomach, some call this condition “retained food”. None of the parents were willing to acknowledge that their child had eaten anything during the night, and the waxy appearance of the material, the inability of water flushes to dissolve the mass, and the smell we often encountered would argue that the food was retained for a long time. Because of the poor outcome in at least one of our children, we do recommend endoscopic removal of the material, even though it can take a considerable amount of time.

In this series of children, the role of gastric emptying remains unclear. We suspect that in the children with normal gastric emptying, the problem may result from abnormal gastric trituration (grinding) more often than with delayed emptying. Interestingly, most of the children subsequently underwent endoscopy without a bezoar being noted, with bezoar recurrence subsequently noted in only 1 case. Therefore, we conclude that gastric bezoars may be a transient problem in many cases. We also propose an algorithm to guide management for pediatric gastric bezoars based on our experience and the literature (Fig. 2).

FIGURE 2: An algorithm to guide management for pediatric gastric bezoars.

CONCLUSION

We conclude that gastric bezoars may be a transient problem in some cases but could be dangerous in others. We propose an algorithm to guide management for pediatric gastric bezoars based on our experience and the literature (Fig. 2).