AIM: To describe the clinical characteristics of patients with gastric or intestinal bezoars recently treated in our hospital.

METHODS: In this study, a retrospective chart review of consecutive patients with gastrointestinal bezoars, who were treated at the Samsun Education and Research Hospital between January 2006 and March 2011, was conducted. Data on demographic characteristics, clinical presentation, history of risk factors, diagnostic procedures, localization of bezoars, treatment interventions, and postoperative morbidity and mortality rates were collected and evaluated.

RESULTS: Forty-two patients [26 (61.9%) males and 16 (31.1%) females] with a mean ± SD (range) age of 55.8 ± 10.5 (37-74) years were enrolled in this study. Thirty-six patients (85.7%) had one or more predisposing risk factors for gastrointestinal bezoars. The most common predisposing risk factor was a history of previous gastric surgery which was identified in 18 patients (42.8%). Twenty three patients (54.8%) had multiple predisposing risk factors. Phytobezoars were identified in all patients except one who had a trichobezoar in the stomach. Non-operative endoscopic fragmentation was performed either initially or after unsuccessful medical treatment in 14 patients with gastric bezoars and was completely successful in 10 patients (71.5%). Surgery was the most frequent treatment method in our study, which was required in 28 patients (66.7%). Intestinal obstruction secondary to bezoars was the most common complication (n = 18, 42.8%) in our study.

CONCLUSION: The presence of multiple predisposing factors may create a synergistic effect in the development of bezoars.

Bezoars can be defined as masses of indigestible, hard materials formed in the gastrointestinal tract. Etymologically, the word bezoar came from the Persian word “padzahr” meaning to expel poison. In some societies, animal bezoars were formerly considered a useful medicine and possessed certain magical properties[1]. In 1854, Quain reported an intragastric alimentary mass in an autopsy and called it a ‘‘bezoar’’[2].

Bezoars can be classified as phytobezoars (undigested vegetables), trichobezoars (hairs), lactobezoars (milk) and pharmacobezoars (medications) according to their composition[3]. They usually form in the stomach and can pass into the small bowel where they occasionally cause obstruction. Phytobezoars are composed of undigested food fibers, such as cellulose, hemicellulose, lignin and fruit tannin. These fibers occur in fruits and vegetables such as celery, pumpkin, prunes, raisins, leeks, beets and persimmons.

The aim of this study was to describe the clinical characteristics of patients with gastric or intestinal bezoars recently treated in our hospital.

A retrospective chart review of consecutive patients with gastrointestinal bezoars, who were treated at the Samsun Education and Research Hospital between January 2006 and March 2011, was conducted. Data on the demographic characteristics, clinical presentations, history of predisposing risk factors, diagnostic procedures, localization of bezoars, treatment interventions, morbidity and mortality rates were collected and evaluated. In addition, the patients were contacted by phone to determine any recurrence of bezoars after treatment.

In this study, previous gastric surgery, excessive consumption of some types of fruit and vegetables, diabetes mellitus, mastication problems, long-term antacid treatment and mental disorders were considered predisposing risk factors in the development of bezoars.

All calculations were performed in Microsoft Office Excel 2007. Continuous variables were summarized as mean ± SD or median when appropriate, and categorical variables as frequency and percentage (%).

A number of predisposing factors may contribute to the risk of bezoar formation. Previous gastric surgery was reported in 20% to 93% of patients with bezoars and the incidence of bezoar formation after gastric surgery ranged from 5% to 12%[4-8]. Similar to previous published studies, the most common predisposing risk factor was previous gastric surgery which was identified in 42.8% of the patients in our study. Altered anatomy and physiology of the gastric remnant after vagotomy and partial gastrectomy are largely responsible for bezoar formation. Vagotomy and partial gastrectomy diminish the ability of the stomach to break up and digest food. Both the quantity and the acidity of the gastric juice are reduced and peptic activity is adversely affected[9,10]. Additionally, the antrum has an important role in the mechanical fragmentation of ingested material, and the pylorus prevents large boluses from reaching the small intestine. Resection of the antrum and pylorus may lead to the passage of a non-fragmented, large bolus to the small intestine. The interval between gastric surgery and bezoar detection was 9 mon to 30 years[4-7]. In our study, the mean interval between surgery and bezoar detection was 7.4 ± 2.3 years (5-11 years).

Excessive consumption of persimmon was identified in 40.5% of our patients. Persimmon, which grows in many areas in our region and widely consumed, is the fruit of a number of species of trees belonging to the genus Diospyros. The word Diospyros means “the fruit of the gods” in ancient Greek. Persimmon bezoars are also known as diospyrobezoars. Unripe persimmons contain soluble tannin. Tannin polymerizes in an acidic environment to form a glue-like coagulum, which can affix to other materials in the stomach[11]. In 1986, Krausz et al[4] reported that 91.2% of 113 patients with phytobezoars had a history of persimmon intake. Erzurumlu et al[12] from our country reported that 17.6% of their 34 patients with bezoars had a history of persimmon or cherry laurel intake.

Mental retardation and trichotillomania are major risk factors for the development of trichobezoars[13]. In our study, there was only one patient with trichobezoar who had a history of psychiatric disorders and trichotillomania. The other predisposing factors observed in our study included mastication problems, diabetic gastroparesis and antacid drug use. Consequently, 85.7% of patients had one or more predisposing factors in our study. While about one third of our patients had only one predisposing risk factor, over fifty percent had multiple predisposing risk factors. In our opinion, these results may indicate that the presence of multiple predisposing risk factors creates a synergistic effect in the development of bezoars. On the other hand, 14.3% of the patients in our study had no apparent predisposing risk factors. Erzurumlu at al[12] reported that only 5.9% of the patients in their study had no apparent predisposing risk factors. Bezoar formation is postulated to be provoked by dietary and eating habits in patients without predisposing factors[14].

Until only a few decades ago, the differential diagnosis of intestinal obstruction secondary to bezoars was difficult before surgery, because the clinical and radiographic findings are similar to those of intestinal obstruction attributable to other causes[11,15]. However, findings from recent studies suggest that sonography or computerized tomography (CT) can assist radiologists in diagnosing bezoars before surgery[6,16]. In our study, PAR showed air-fluid levels in 18 patients with intestinal obstruction. The typical bezoar image on PAR, involving a mottled air pattern, was identified in only two patients (11.1%). Abdominal CT was carried out in 16 patients and bezoars were revealed in 14 (77.7%) of these patients before surgery. Although sonography was not the preferred imaging modality for the patients with intestinal obstruction in our study, it was carried out in 12 patients with gastric bezoar as the first imaging method and the presence of a bezoar was suspected in 7 (58.3%) of these patients before endoscopy.

Both mechanical and chemical procedures are used in the treatment of gastric bezoars. Bezoars can be endoscopically fragmented into pieces using polypectomy snares, endoscopic forceps, Dormia baskets, endoscopic lithotripsy, electrosurgical knives or YAG laser. However, this technique requires specific equipment and is not complication free. Bleeding, perforation or even migration of bezoar pieces causing intestinal obstruction are potential complications[17]. In our study, endoscopic fragmentation was performed either initially or after unsuccessful medical treatment in 14 patients and was completely successful in 10 patients (71.5%). Medical treatment may also be useful in the management of gastric bezoars. Several chemical agents have been tested; these are administered orally, through a nasogastric tube or injected directly into the bezoar via endoscopy. However, the development of these techniques usually takes time, is not free of complications such as electrolytic disorders, gastric ulcer and has indistinct results[17]. In our study, medical treatment was initially tried in 15 cases with gastric bezoars, but was completely successful in only 4 patients (26.7%).

Although bezoars are the most common type of foreign body lodged in any part of the gastrointestinal tract, the overall incidence of bezoar-induced intestinal obstruction remains relatively low. Epidemiological data show that 2% to 4% of intestinal obstructions are caused by bezoars[2]. This figure was 7% in our study. Although intestinal obstruction was reported to be the most frequent clinical presentation of bezoars in the majority of previous studies, it was observed in 42% of the patients in our study. Surgical management of intestinal obstruction secondary to bezoars entails milking the object into the cecum or performing enterotomy for retrieval in difficult cases. In our study, 47% of patients with intestinal obstruction were managed by milking. Enterotomy was performed in 53% of patients with intestinal obstruction. Although therapeutic laparoscopy has been demonstrated to be feasible in the management of intestinal obstruction secondary to bezoars[18], all operations were conducted as open surgery in our study.

Intestinal bezoars are often found in association with gastric bezoars[6]. Coexisting gastric bezoars was reported in 17%-21% of patients[19-21]. In our study, a coexisting gastric bezoar was found in 22.2% of patients with an intestinal bezoar. Consequently, when an intestinal bezoar is diagnosed, the possible presence of coexisting gastric or intestinal bezoars should be investigated cautiously.

Major complications of bezoars other than intestinal obstruction include gastric ulcer, gastritis, gastric perforation and gastric outlet obstruction. In our study, coexisting gastric ulcers were identified in 20.8% patients with gastric bezoars. While anti-ulcer medication was prescribed in endoscopically treated patients, wedge resection of ulcers was added to the gastrotomy in operated patients. Two patients with gastric outlet obstruction were treated with gastrotomy and extraction of bezoars.

Although, there was no clinical recurrence of bezoars during a median follow-up time of 25 mo after treatment in our study, Klamer et al[22] reported recurrence in approximately 20% of patients with gastric bezoars after initial treatment. Therefore, patients should be instructed to avoid a high fiber diet, persimmons and certain medications to minimize the potential risk of recurrence.

In conclusion, over fifty percent of the patients in our study had multiple predisposing factors for gastrointestinal bezoars. In light of these results, it may be concluded that the presence of multiple predisposing factors create a synergistic effect in the development of bezoars. Intestinal obstruction is the most common complication of bezoars. Although the prevalence of intestinal obstruction secondary to bezoars is quite low, differential diagnosis of intestinal obstruction secondary to adhesions is important in patients with previous abdominal surgery; CT can help to make this differentiation. Therefore, CT should be obtained whenever possible in all patients with bowel obstruction to establish the diagnosis and avoid inappropriate treatment.