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Bezoars, Pediatric

Basics

Description

- 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

- 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

- 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 - 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

  • 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

  • TrichobezoarsAssociated with mental retardation, pica, trichotillomania, and trichophagia; may ingest own hair but also rugs and animal or doll hairMost 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 foldsTrichobezoars 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.
  • PhytobezoarsMost common form among adults, rare in childrenAssociated with gastric dysmotility and poor gastric emptying (either primary or following gastric surgery) and hypochlorhydriaComposed 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 contentEarly and rapid feeding advancement in small infantsHigh-caloric-density formulasFormulas with high calcium/phosphate contentContinuous tube feedingsAltered 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 bodiesGallstonesMedications, including vitamins, antacids, psyllium, sucralfate, cimetidine, and nifedipine
  • Can occur in cystic fibrosis (CF) patients after lung transplantation
  • Colonic and rectal bezoarsDue to indigestible sunflower seeds, popcorn, and gum have been reported in children and adultsThese usually present with obstruction, although encopresis and colitis-type symptoms have been described.

Diagnosis

History

  • Signs and symptoms of bezoar formation include the following:PainHalitosisNauseaVomitingDiarrheaGastric ulcerationUpper GI bleeding and perforationLeft upper quadrant mass
  • TrichobezoarsUnusual patterns of baldingPalpable left upper quadrant mass in the abdomen is often detected.Hair found in the stool
  • PhytobezoarsAbdominal mass is palpable in <50% of patients.
  • LactobezoarsAbdominal 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-rayHeterogenous intragastric mass that could be mistaken for food-filled stomach
  • Upper GI barium studiesMay 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

  • TrichobezoarsDifficult to remove endoscopically, attempts to fragment may result in migration and small bowel obstructionTreatment is usually surgical removal: Trichobezoars are normally large and hair is not dissolvable.
  • PhytobezoarsMedications such as prokinetic agents to stimulate gastric motilityEnzyme therapy to help dissolve the materialN-acetylcysteine treatment via nasogastric tube has been documented in one case report.Endoscopic fragmentation or extractionCoca-Cola administration with or without endoscopic extraction has been reported to be effective.Surgical extractionDiet alteration
  • LactobezoarsWithholding 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.