Secondary Logo

Journal Logo

Original Articles: Gastroenterology

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

Shah, Monisha; Wan, David Q.; Liu, Yuying; Rhoads, Jon Marc

Author Information
Journal of Pediatric Gastroenterology and Nutrition: February 2021 - Volume 72 - Issue 2 - p e31-e36
doi: 10.1097/MPG.0000000000002923
  • Free

Abstract

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.

F1
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).

F2
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).

REFERENCES

1. Mezoff EA, Mezoff AG. Bezoars 2016; 2:340–342.
2. Chen TY, Tiao MM, Chuang JH, et al. Bezoars in children: report of four cases. J Formos Med Assoc 2000; 99:726–729.
3. Sehgal VN, Srivastava G. Trichotillomania +/- trichobezoar: revisited. J Eur Acad Dermatol Venereol 2006; 20:911–915.
4. Zamir D, Goldblum C, Linova L, et al. Phytobezoars and trichobezoars: a 10-year experience. J Clin Gastroenterol 2004; 38:873–876.
5. Mihai C, Mihai B, Drug V, et al. Gastric bezoars--diagnostic and therapeutic challenges. J Gastrointestin Liver Dis 2013; 224:111.
6. Akbulut S, Deger KC, Duman M, et al. Gastric bezoars. Prz Gastroenterol 2016; 11:60–61.
7. Gorter RR, Kneepkens CM, Mattens EC, et al. Management of trichobezoar: case report and literature review. Pediatr Surg Int 2010; 26:457–463.
8. Pogorelic Z, Juric I, Zitko V, et al. Unusual cause of palpable mass in upper abdomen--giant gastric trichobezoar: report of a case. Acta Chir Belg 2012; 112:160–163.
9. Bitar DE, Holmes TW Jr. Polybezoar and gastrointestinal foreign bodies in the mentally retarded. Am Surg 1975; 41:497–504.
10. Yakan S, Sirinocak A, Telciler KE, et al. A rare cause of acute abdomen: small bowel obstruction due to phytobezoar. Ulus Travma Acil Cerrahi Derg 2010; 16:459–463.
11. Ghosheh B, Salameh JR. Laparoscopic approach to acute small bowel obstruction: review of 1061 cases. Surg Endosc 2007; 21:1945–1949.
12. DeBakey M, Ochsner A. Bezoars and concretions. Surgery 1938; 4:934–936.
13. Ladas SD, Kamberoglou D, Karamanolis G, et al. Systematic review: coca-cola can effectively dissolve gastric phytobezoars as a first-line treatment. Aliment Pharmacol Ther 2013; 37:169–173.
14. Nelson A, Romo N, Levanon D, et al. Gastric bezoar treatment using oral coca-cola. Clin Pediatr (Phila) 2017; 56:485–487.
15. Paschos KA, Chatzigeorgiadis A. Pathophysiological and clinical aspects of the diagnosis and treatment of bezoars. Ann Gastroenterol 2019; 32:224–232.
Keywords:

abdominal pain; early satiety; foreign body; gastric; gastric emptying; nausea and vomiting

Copyright © 2020 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition