A gastric bezoar is a compact mass of indigestible foreign materials that accumulate and consolidate in the stomach; however, it can be found in other sites of the gastrointestinal tract. The causative manner of this condition is complex and multifactorial. The main purpose of the review was to raise awareness among clinicians, particularly gastroenterologists, that patients with certain risk factors or comorbid conditions are predisposed to gastric bezoar formation. Early diagnosis and prompt intervention are crucial to avoid bezoar-induced complications. Upper gastrointestinal endoscopy is the standard diagnostic and therapeutic method for gastric bezoars. However, for large size bezoars, surgical intervention is needed.
Bezoars are congregations or compact masses that formed by the accumulation of matter, especially nonedible materials, including high-fiber vegetable diet, hair, and certain pharmaceutical agents. They are found more frequently in the stomach in patients with normal or abnormal gastric function or in patients with poor gastric peristalsis resulting in delayed gastric draining and other associated disorders [
The majority of gastric bezoars are found to be present in adolescents and young ladies with a history of pica, predominantly psychiatric disorders. In contrast to adults, the majority of gastric bezoars are associated with gastroparesis, anatomical abnormalities, and former gastric surgeries that reduced gastric motility and ultimately resulting in delayed stomach emptying [
The most common clinical presenting symptoms in patients with gastric bezoars include nausea and vomiting, epigastric pain, dyspepsia, and weight loss [
Bezoars occur most commonly in people with certain risk factors (Table
Most common risk factors associated with gastric bezoars.
Fibers rich diet | Milk products | Medications | Pica consumption | Mastication disorders | Insufficient fluid intake | Honeycomb consumption | |
---|---|---|---|---|---|---|---|
Risk factors | Vegetarians | Synthetic milk | Overdose medicines | Nonnutritive constituents | Dental status | Elder people | Patients with large quantity of honeycomb ingestion for multiple health benefits |
Fiber-rich fruits | Feeding method | Medication for suicidal attempt | Pregnant women and small children | Abnormal mastication | Labors in hot climate | ||
Patient with partial gastrectomy on a high-fiber diet | Premature birth | Bulk-forming agents | Patients with autism | Denture wearers | Inadequate fluid ingestion | ||
Failure to thrive | Extended-release medications | Patients with bariatric surgery | Kidney disease | ||||
Anemic children |
Most common comorbid conditions associated with gastric bezoars.
Medical disorders | Anatomic abnormalities | Gastric motility disorders | |
---|---|---|---|
Comorbid conditions | Rapunzel syndrome |
Gastric diverticula |
Gastroparesis |
Bezoars are categorized according to the following materials that form them.
Phytobezoars or diospyrobezoar: composed of indigestible fruit or vegetable content Trichobezoars: composed of hair Lactobezoars: composed of milk products Pharmacobezoars: composed of tablets and medications
Hypothetically, the partially digested and undigested materials accompanied by gastric mucus can be a source of gastric bezoar.
Diets with high-fiber content (vegetables and fruits, i.e., cellulose) are more common in regions where cultures/beliefs play a key role in consumption [
A gastric lactobezoar is a mass composed of a specific form of inspissated milk and mucus components [
Pharmacobezoars are characterized by aggregations of medicines that do not properly liquefy in the GI tract and can be found in patients taking a pharmaceutical agent, tablets or somewhat liquid masses of drugs; they are usually found following an overdose of medications or in a suicidal attempt [
Pica consumption is closely linked to buildup gastric mass characterized by mainly nonnutritious materials, such as ice, pagophagia; paper, papyrophagia; drywall or paint; metal, metallophagia; stones, lithophagia; soil, geophagia; glass, hyalophagia; feces, coprophagia; and chalk. Pica consumption is most frequently found in pregnant women, small children, and those with developmental abnormalities, such as autism [
Mastication is a multifactorial semiautonomic sensory motor pathway by which food content is converted into a bolus throughout the course of intraoral manipulation. Influencing factors involve dental status, active adaptation in conducting mastication during bolus formation and properties amalgamation of a bolus which may increase the possibility of GI diseases and reduce gut absorption. Mastication efficacy in denture wearers and dentate subjects is vastly different. In denture wearers, the mastication is known to be highly impaired during bolus formation. In addition to abnormal chewing behaviors and gastric motility, delay gastric emptying occurs due to large fragmented gastric bolus and consequently multiple gastric anomalies [
Fluids play a critical role in the regularity and the avoidance of GI disorders. Dietary fluid intake and renal excretion regulate total body sodium content. Inadequate fluid intake causes low blood pressure, constipation, kidney disease, electrolyte imbalance, mental changes, and dry stomach. Adequate fluids provide the source for the production of mucus in the GI tract and keep things lubricated and moistened, and thereby, the food bolus and stool can easily move through the GI tract and thus prevented GI disorders [
Recently, honeycomb consumptions are widely used for various health purposes such as heart diseases, liver diseases, and metabolic disorder. However, ingesting a huge quantity of honeycomb may cause GI obstruction and life-threatening consequences. Moreover, Katsinelos et al. [
Trichobezoar commonly appears in patients with a history of Rapunzel syndrome. In this condition, patients have significant psychological or behavioral abnormalities most commonly found in females and can be associated with trichotillomania and trichotillophagia (urge to pullout one’s own hair) combined with trichophagia [
Amyloidosis is a condition caused by deposition of unsolvable abnormal (misfolded protein) amyloid fibrils that modify the normal function of organs and tissues [
Certain comorbid conditions [
A gastric diverticulum is a rare cause of gastric bezoar when a bulk of undigested food remnant expelled from the diverticula of size (1-10 cm). It can be categorized into congenital type and acquired type. The congenital type being more common and less involved in gastric mass formation compared to acquired type is mostly found in the posterior wall of the fundus and account for about 70%. The false diverticula are usually located in the gastric antrum and greater curvature with a contextual history of chronic GI diseases, such as peptic ulcer, pancreatitis, malignancy [
Pyloric stenosis is a tightening of the pyloric canal most frequently found in infants with a cesarean section or preterm birth [
Rarely, gastric bezoars formed when gallstone migrated to the stomach through a cholecystogastric fistula [
Gastroparesis or gastric stasis is a disorder that affects gastric muscle activity, and consequently, foodstuff rests in the stomach for a prolonged time [
The majority of gastric bezoars develop in patients with previous gastric surgeries such as Laparoscopic adjustable gastric banding [
Gastric bezoars are usually asymptomatic. They are rarely suspected by referring clinicians except in psychiatric patients. They often cause ulceration due to pressure necrosis, pyloric obstruction, peritonitis, and rarely perforation [
(a) Upper GI endoscopy showing a giant
A summary table with case studies regarding gastric bezoars.
Case no. A/G |
History/previous operation | Symptoms | Clinical findings | Locations of bezoar in the stomach | Size of bezoar (cm) | Associated gastric lesions | Composition of the bezoar | Management | Complications |
---|---|---|---|---|---|---|---|---|---|
(1) 49/M [ |
Habitual jujubes ingestion | Epigastric pain |
Anemic |
Body | Necrotic ulcer | Jujubes (diospyrobezoar) | Coca-Cola |
None | |
(2) 18/F [ |
Trichophagia (Rapunzel syndrome) | Acute abdominal pain |
Weight loss | Full-length | 120 cm | Ulcer | Hair (trichobezoar) | Laparotomy | Gastric perforation |
(3) 47/M [ |
6-month | Epigastric pain | Weight loss | Body | None | Phloem fibers |
Laparotomy | None | |
(4) 76/M [ |
Arterial hypertension | Dyspepsia |
None | Body | 10 cm | Ulcer | Vegetable fibers (phytobezoar) | Endoscopic (polypectomy snare) | None |
(5) M [ |
None | Abdominal pain |
Weight loss | Body | N/A | None | Fatty acids and lecithin (phytobezoar) | Surgical removal | None |
(6) 96 cases |
Prematurity |
Abdominal distension |
Palpable abdominal mass | N/A | N/A | None | High casein content 54.2%, medium chain triglycerides 54.2% |
Cessation of oral feedings administration of intravenous fluids |
Perforations (7 patients) |
(7) 44/F [ |
Anxiety disorder | Semiconscious |
Potassium overdose (hyperkalemia) |
Gastric fundus | N/A | None | Extended-release potassium chloride (pharmacobezoar) | Whole bowel irrigation using polyethylene glycol (NG tube) |
None |
(8) 60/F [ |
Open cholecystectomy and choledicholithotomy | Epigastric pain |
Mildly anemic |
Pyloric canal | N/A | None | Aluminum hydroxide tablets (pharmacobezoar) | Endoscopic removal using biopsy forceps and Dormia basket | None |
(9) 58/M [ |
3-month |
Abdominal pain |
Circumferential wall thickening of pylorus | Pylorus | N/A | Gastritis noncaseating epithelioid |
Mesalamine pills (pharmacobezoar) | Laparoscopic gastrojejunostomy | Gastric outlet obstruction |
(10) 54/M [ |
Primary lung cancer (metastatic) |
Hyperkalemia | Constrictive effusive metastatic pericarditis kidney failure | Body | None | Sodium polystyrene sulfonate (pharmacobezoar) | Postmortem | Expired | |
(11) 7/M [ |
Pica | Abdominal pain |
Abdominal tenderness guarding | Full-length gastric bezoar | None | Wooden bezoar | Laparoscopic |
Gastric perforation | |
(12) 53/F [ |
Pica |
Severe personality disorders |
Mild abdominal distention | N/A | None | Cardboard and newspaper | Endoscopic removal |
None | |
(13) |
Denture wearers |
Not mentioned | Muscle bursts were longer = lower muscle work |
N/A | N/A | N/A | Chewing of paraffin and meat | N/A | Impaired chewing in complete denture wearers modifies the dynamics of meat bezoar formation due to large fragmented bolus |
(14) 44/F [ |
Irritable bowel syndrome |
Epigastric pain |
None | Body | N/A | N/A | Honeycomb | Endoscopic removal |
None |
(15) 69/F [ |
Cholelithiasis |
Right-sided upper abdominal pain |
Multiple biliary stones in the common bile duct | Pylorus and duodenal bulb | N/A | N/A | Gallstones and indigestible material | Proton pump inhibitor and cola drink | None |
(16) 14/F [ |
Anorexia nervosa |
Nausea and vomiting | Weight loss |
Full-length |
N/A | None | Hair (trichobezoar) | Laparotomy | None |
(17) 45/F [ |
Habitual consumption of cows’ feet stew with hair and skin intact. |
Dysphagia |
Microcytic anemia |
Lesser curvature | 2.42 kg | Ulcer at the lesser curvature | Mass of hair |
Laparotomy |
None |
(18) 19/F [ |
Anorexia nervosa |
Nausea and vomiting |
Weight loss |
Vomited a cylindrical bezoar from the stomach | 4 cm | Possible erosions or ulcer | Debris and birefringent |
Conservative treatment | N/A |
(19) 21/F [ |
Bulimia nervosa |
Abdominal pain |
Afebrile, normotensive with mild tachycardia |
Greater curvature overlying the pylorus | None | Food matter | Coca-Cola |
None | |
(20) 3/F [ |
Sickle cell disease | Upper abdominal pain |
Large intra-abdominal mass epigastric tenderness |
Stomach extended to the duodenum | N/A | Trichobezoar | Laparotomy |
None | |
(21) 62/F [ |
Multiple myeloma | Epigastric pain |
Elevated IgG of 49.2 g/L |
Body extended pylorus | N/A | Mild focal intestinal metaplasia and glandular atrophy | Phytobezoar | Coca-Cola pancreatic enzyme supplementation | Expired in 1 month |
(22) 42/F [ |
Hypertension |
Nausea and vomiting |
Obese, epigastric tenderness |
Antrum | N/A | Cholesterol gallstone induced bezoar | Laparotomy |
None | |
(23) 34/F [ |
Laparoscopic adjustable gastric banding | Epigastric fullness |
Obese |
In eccentric pouch dilatation | N/A | N/A | Bezoar | Liquid diet |
Anterolateral slippage of the band |
(24) 48/M [ |
Laparoscopic adjustable gastric banding | Dysphagia | N/A | Body | N/A | Erosions | Phytobezoar | Papain (1 week) | None |
(25) 70/M [ |
Cholecystogastric fistula | Painful lump in the right hypochondriac region with fever and anorexia | CT revealed fistula between the gallbladder and gastric antrum. | Antrum | Fistulous opening in the prepyloric region | Gallstone bezoar |
Laparotomy | None | |
(26) 63/F [ |
Roux-en-Y gastric bypass | Abdominal distention |
Morbid obese (body mass index 49.5 kg/m2) |
Gastric pouch | 5 cm | None | Persimmon |
Endoscopic |
None |
(27) 65/M [ |
Chestnuts consumption | Abdominal pain | Abdominal CT indicated gastric perforation | Lesser curvature | N/A | Ulcer | Tannin |
Surgery |
Gastric perforation |
(28) 73M/58F [ |
(2 cases) |
N/A | Cancer |
Proximal gastric pouch | 10 cm |
N/A | Phytobezoar | 200 micron laser fiber and 550 micron laser fiber (Ho:YAG laser) | None |
(29) 62/F [ |
Acute gastritis and gallstones | Epigastric pain |
Abdominal tenderness |
Body | N/A | Gastric angle with multiple lesions |
Bezoar | Chinese medicine purgative combined with pantoprazole sodium intravenous infusion, 40 mg each time, twice a day for 5 days | None |
A/G: age/gender; M: male; F: female; NA: not available; cm: centimeter.
An abdominal examination has limited the efficacy in identifying gastric masses; though, sometimes on abdominal palpation intragastric mass or halitosis from the putrefying items can be found. However, these observations are not definitive and much harder to differentiate.
Upper GI series is the first step in diagnosis gastric bezoar if suspected. Appearance on CT is a mass-like filling defect with various composition-dependent characteristics. Trichobezoars often have a lamellated appearance. The gold standard for imaging is direct visualization with upper GI endoscopy for both diagnostic and therapeutic purposes [
Gastric bezoars can be managed either medicinally, endoscopic, or surgically. Bezoars with small size may pass via the GI tract freely on their own. In the management of gastric bezoars, there are three most common approaches which mostly focus on dissolution or eliminating bezoars. (1) Enzymatic treatment (Coca-Cola irrigations, gastroprokinetic agents, and enzymes cellulose) [
Gastric bezoars most frequently occur in patients with certain risk factors including psychiatric conditions, anatomic anomalies, and weakened gastric motility or in patients with coexisting medical conditions. Early diagnosis and appropriate treatment strategy are essential to prevent bezoar-induced complications. Upper GI endoscopy is a safe and effective procedure for diagnostic and therapeutic purposes of gastric bezoars. Besides, careful endoscopic surveillance should be carried out if the bezoars recur repeatedly, especially in patients with anatomical abnormalities or previous gastric surgeries. There could be a number of other contributing factors that can lead to gastric bezoar but have not yet been known to the clinicians. However, further studies are required to address this issue.
Gastrointestinal
Holmium:YAG.
The authors report no conflicts of interest.
All the names of the persons who have made substantial contributions to the work reported in the manuscript are declared in the author list. SK contributed to the paper in writing, data collection, data analysis, and manuscript preparation. KJ and LZ contributed in literature search and in the definition of intellectual content. IAK, KU, and SK contributed to the final review. XC and BMW contributed to the study concept, design, manuscript editing, and manuscript review. All authors read and approved the final manuscript.
This work was supported by the Science and Technology Program of Tianjin (15ZXJZSY00020) and the Natural Science Foundation of Tianjin (18JCZDJC45200).