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.
