Pathophysiological and clinical aspects of the diagnosis and treatment of bezoars

Abstract

Bezoars are intraluminal conglomerates of indigestible foreign materials that accumulate in the gastrointestinal (GI) tract. They consist of vegetable or fruit fibers, hairs or other substances; accordingly, bezoars are classified as phytobezoars, trichobezoars, pharmacobezoars, etc. Although sometimes asymptomatic, bezoars may cause serious symptoms, such as abdominal discomfort or pain, dysphagia, hematemesis, or even life-threatening entities (GI bleeding, obstruction or perforation). Current technological applications have contributed to the diagnostic and therapeutic approach to these masses, mainly through endoscopic techniques able to diagnose, fragment and extract bezoars, as well as laparoscopic and other surgical modalities that may be used to treat serious complications. Although bezoars were described centuries ago and the term was officially introduced in the mid nineties by Quain, they are still a demanding pathological entity. Their pathophysiology, accurate and prompt diagnosis, as well as successful and minimally invasive treatment, remain under investigation and see continuous progress. Current advances in these challenging areas are discussed in this review, which attempts to present an in-depth study of bezoars along with the well-established modalities and techniques.

Keywords: Bezoar; endoscopy; ileus; intestinal obstruction; phytobezoar.

Figure 1

Abdominal radiography with per os administration of an iodinated contrast medium shows a gastric phytobezoar as a filling defect (arrow)

Figure 2

Contrast-enhanced computed tomography showing a phytobezoar in ileal loops causing intestinal obstruction (characteristic mottled appearance)

Figure 3

Therapeutic approach following the diagnosis of a gastric or intestinal bezoar. There are multiple options, including chemical dissolution, endoscopic removal, laparoscopic or open surgery

Figure 4

Enterotomy performed via laparotomy on a 68-year-old man to remove an ileal phytobezoar (15×5 cm) causing intestinal obstruction (intraoperative and radiological-computed tomography image)

Figure 5

Gastric phytobezoar (grape skins and seeds) discovered in a 52-year-old man and treated with CocaCola® per os (A. retroflexed view, B. forward view)

Figure 6

(A) Contrast-enhanced computed tomography showing a duodenal phytobezoar (arrow). (B) Phytobezoar (5×10 cm) fragmentation in the stomach with an ordinary oval 30 mm polypectomy snare (endoscopic view)

Figure 7

(A) Large ileus phytobezoar (75×8 cm) that caused obstruction and perforation of the small bowel. (B) Intraoperative and radiological-computed tomography image (arrow)