Gastric Bezoar

A gastric bezoar is an intragastric mass of indigestible material that fails to pass through the pylorus.

Important types are:

Phytobezoar: vegetable and fruit fibre, the commonest type
Trichobezoar: hair, usually associated with trichotillomania and trichophagia
Pharmacobezoar: concreted medication
Lactobezoar: concentrated milk material, mainly in infants

Predisposing factors are impaired gastric emptying and altered gastric anatomy. Previous vagotomy, pyloroplasty, partial gastrectomy, diabetes with gastroparesis and poor dentition are particularly relevant.

Persimmon phytobezoars are unusually hard because tannins polymerise within the acidic stomach and are more resistant to chemical dissolution.

Small bezoars may be incidental.

Larger bezoars cause early satiety, epigastric discomfort, nausea, vomiting, anorexia and weight loss.

Complications include:

Gastric outlet obstruction
Gastric ulceration and bleeding
Small bowel obstruction after distal migration
Perforation, rarely

A trichobezoar extending from the stomach into the small bowel is termed Rapunzel syndrome and can produce obstruction, ulceration or perforation.

Upper gastrointestinal endoscopy: confirms the bezoar, defines its composition and size, assesses associated ulceration and allows treatment.

CT abdomen: use when small bowel obstruction, perforation or distal migration is suspected.

The underlying cause should also be identified. A bezoar in an adult without obvious anatomical explanation should prompt assessment for gastroparesis, previous surgery, medication effects or impaired mastication.

Treatment depends on composition and complications.

Phytobezoar

Chemical dissolution can be attempted in a stable patient without perforation, major bleeding or distal obstruction.

Coca Cola has been used successfully to soften and dissolve phytobezoars. A commonly described regimen is approximately 3 litres administered orally or through a nasogastric tube over about 12 hours, although there is no universally standardised dose. It is often more useful as a softening treatment before endoscopic fragmentation than as definitive treatment alone.

Avoid this strategy in patients at high aspiration risk, significant fluid restriction or poorly controlled diabetes without appropriate modification.

Persimmon bezoars commonly require endoscopic fragmentation because they are relatively resistant to dissolution.

Endoscopic treatment

Endoscopic fragmentation and removal is appropriate when:

Dissolution fails
Symptoms are significant
Gastric outlet obstruction is developing
The bezoar is large or hard
Associated ulceration or bleeding requires treatment

Snares, retrieval nets, baskets and forceps can be used to fragment and extract the mass.

Fragments should be reduced sufficiently to avoid creating a downstream small bowel obstruction.

Trichobezoar

Trichobezoars respond poorly to chemical dissolution because compacted hair is resistant to enzymatic degradation. Large trichobezoars usually require surgical removal, particularly when there is Rapunzel syndrome or extension beyond the stomach.

At surgery, inspect the small bowel for satellite bezoars before closure.

Treat associated psychiatric disease to reduce recurrence.

Surgery

Operate for:

Perforation
Small bowel obstruction not amenable to endoscopic treatment
Major uncontrolled bleeding
Large trichobezoar
Failed endoscopic therapy
Bezoar too large or dense for safe fragmentation

After removal, treat the underlying gastric emptying disorder and address dietary factors because recurrence is otherwise possible.

Crohn Abscess

A Crohn abscess results from penetrating transmural disease with a contained perforation and intra abdominal or pelvic pus collection.

It commonly coexists with a diseased ileal segment, stricture or fistula. Antibiotics alone often fail when a mature collection remains undrained.

The preferred sequence is control of infection first, followed by definitive treatment of the diseased bowel after physiological and nutritional optimisation.

Start antibiotics covering enteric Gram negative organisms and anaerobes.

A practical adult regimen is:

Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.

For severe sepsis or substantial resistant organism risk:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Drain a well defined accessible abscess percutaneously.

Send aspirated material for culture.

Do not escalate corticosteroids or other immunosuppression into an uncontrolled undrained abscess.

After drainage, optimise nutrition and reassess the diseased bowel. Many patients with associated stenosis, fistula or medically refractory disease ultimately benefit from elective resection after sepsis has settled. Surgery approximately 2 to 4 weeks after successful drainage is often a useful window when recovery permits, although timing should remain individualised.

Operate urgently for generalised peritonitis, free perforation, failed drainage or persistent uncontrolled sepsis.

At definitive surgery, resect the responsible diseased segment rather than simply draining the abscess and leaving a severely stenosed or penetrating segment untreated.

Gastric Bezoar

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management