Basics
Description
- Accumulation of foreign material in the gastrointestinal (GI) tract
- Commonly divided into 3 categories based on the substances from which the bezoar is derived:
- Phytobezoar (from vegetables/fruits)
- Trichobezoar (hair)
- Lactobezoar (milk/formula)
- Documented to occur in humans for more than 2 millennia, suggesting formation of bezoars may have been/still be culturally important for certain societies
Epidemiology
- Phytobezoars occur almost exclusively in adults.
- 90% of trichobezoars occur in female patients younger than 20 years of age.
- Lactobezoars occur mostly in premature, low-birth-weight infants.
Pathophysiology
- Trichobezoars
- Associated with mental retardation, pica, trichotillomania, and trichophagia; may ingest own hair but also rugs and animal or doll hair
- Most cases of trichophagia do not result in bezoar formation (~1%).
- History of trichophagia is obtained in only 50% of cases.
- Retention and accumulation of hair strands in the gastric folds
- Trichobezoars may become large and form a cast in the stomach leading to abdominal mass.
- Bezoar may extend through the pylorus into the small bowel. This "tail" may obstruct the ampulla of Vater, leading to jaundice and pancreatitis. This phenomenon is commonly referred to as Rapunzel syndrome.
- Phytobezoars
- Most common form among adults, rare in children
- Associated with gastric dysmotility and poor gastric emptying (either primary or following gastric surgery) and hypochlorhydria
- Composed primarily of cellulose, hemicellulose, lignins, and tannins
- Lactobezoars (milk)
- Most often reported in premature, low-birth-weight infants being fed high-calorie premature formula (although there are reports in full-term infants and exclusively breastfed infants)
- Factors contributing to lactobezoar formation include the following:
- Formulas with high casein content
- Early and rapid feeding advancement in small infants
- High-caloric-density formulas
- Formulas with high calcium/phosphate content
- Continuous tube feedings
- Altered gastric motility in low-birth-weight infants
Etiology
Classification of bezoars is dependent on the most prominent substance from which they are formed, including:
- Trichobezoars: hair, carpet
- Phytobezoars: indigestible fruit and vegetable matter
- Lactobezoars: milk
- Less common materials include the following:
- Foreign bodies
- Gallstones
- Medications, including vitamins, antacids, psyllium, sucralfate, cimetidine, and nifedipine
- Can occur in cystic fibrosis (CF) patients after lung transplantation
- Colonic and rectal bezoars
- Due to indigestible sunflower seeds, popcorn, and gum have been reported in children and adults
- These usually present with obstruction, although encopresis and colitis-type symptoms have been described.
Diagnosis
History
- Signs and symptoms of bezoar formation include the following:
- Pain
- Halitosis
- Nausea
- Vomiting
- Diarrhea
- Gastric ulceration
- Upper GI bleeding and perforation
- Left upper quadrant mass
- Trichobezoars
- Unusual patterns of balding
- Palpable left upper quadrant mass in the abdomen is often detected.
- Hair found in the stool
- Phytobezoars
- Abdominal mass is palpable in <50% of patients.
- Lactobezoars
- Abdominal distention, diarrhea, emesis, and increased gastric residuals
Diagnostic Tests & Interpretation
Lab
- Iron deficiency anemia
- Presence of steatorrhea or protein-losing enteropathy
Imaging
- Plain abdominal x-ray
- Heterogenous intragastric mass that could be mistaken for food-filled stomach
- Upper GI barium studies
- May identify and outline the mass
- Ultrasound and CT can also be helpful.
Diagnostic Procedures/Other
Endoscopy allows for direct visualization and elucidation of composition of bezoar.
Differential Diagnosis
Any gastric foreign body can mimic a gastric mass and may present on palpation.
Treatment
General Measures
- Trichobezoars
- Difficult to remove endoscopically, attempts to fragment may result in migration and small bowel obstruction
- Treatment is usually surgical removal: Trichobezoars are normally large and hair is not dissolvable.
- Phytobezoars
- Medications such as prokinetic agents to stimulate gastric motility
- Enzyme therapy to help dissolve the material
- N-acetylcysteine treatment via nasogastric tube has been documented in one case report.
- Endoscopic fragmentation or extraction
- Coca-Cola administration with or without endoscopic extraction has been reported to be effective.
- Surgical extraction
- Diet alteration
- Lactobezoars
- Withholding feedings for 48 hours while the patient is sustained on intravenous (IV) fluids will resolve most lactobezoars.
- Gentle gastric lavage may be helpful.
Additional Reading
- Chogle A, Bonilla S, Browne M, et al. Rapunzel syndrome: a rare cause of biliary obstruction. J Pediatr Gastroenterol Nutr. 2010;51(4):522-523. [View Abstract]
- DuBose TM V, Southgate WM, Hill JG. Lactobezoars: a patient series and literature review. Clin Pediatr. 2001;40(11):603-606. [View Abstract]
- 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(2):169-173. [View Abstract]
- Lynch KA, Feola PG, Guenther E. Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department. Pediatr Emerg Care. 2003;19(5):343-347. [View Abstract]
- Taylor JR, Streetman DS, Castle SS. Medication bezoars: a literature review and report of a case. Ann Pharmacother. 1998;32(9):940-946. [View Abstract]
Codes
ICD09
- 938 Foreign body in digestive system, unspecified
- 935.2 Foreign body in stomach
- 936 Foreign body in intestine and colon
ICD10
- T18.9XXA Foreign body of alimentary tract, part unspecified, initial encounter
- T18.2XXA Foreign body in stomach, initial encounter
- T18.3XXA Foreign body in small intestine, initial encounter
SNOMED
- 235677003 Bezoar (disorder)
- 235680002 Phytobezoar (disorder)
- 235679000 Trichobezoar (disorder)
- 235682005 Lactobezoar (disorder)
FAQ
- Q: What are some commonly used medications that can lead to bezoar formation?
- A: Vitamins, antacids, psyllium, sucralfate, cimetidine, and nifedipine
- Q: What may place an infant at risk for formation of a bezoar?
- A: The literature suggests that formulas with high casein content may be linked with lactobezoar formation. Other possible contributing factors include early and rapid feeding advancement in small infants, high-density formulas, formulas with a high calcium/phosphate content, continuous tube feedings, and altered gastric motility in low-birth-weight infants.