Bezoars

Concretions of ingested foreign material (animal or vegetable) that remain in the gastrointestinal tract.

The formation of bezoars is usually related to altered gastric physiology with impaired gastric emptying due to vagotomy, antral resection, gastroparesis, or gastric outlet obstruction. Poor mastication, in which food particles are insufficiently broken, and the consumption of large quantities of indigestible solids may also precipitate bezoar formation.

Bezoars most frequently occur in the elderly, especially in elderly diabetic patients, in whom gastric emptying is severely abnormal. An edentulous patient may be at risk because of poor mastication.

Symptoms, Signs, and Diagnosis

A variety of symptoms and signs can occur, including early satiety, nausea, vomiting, and epigastric pain. Complications (eg, localized ulceration and bleeding) have been reported. Physical findings include the presence of a mass, succussion, or evidence of gastrointestinal bleeding from secondary ulceration. Abdominal x-rays may identify the presence of a foreign body. Endoscopy or barium swallow usually confirms the diagnosis.

Treatment

The treatment of bezoars depends on their composition. Prokinetic drugs (eg, metoclopramide, cisapride), manual disruption, and lavage with a large-bore orogastric tube may facilitate passage. However, metoclopramide can cause adverse reactions in the elderly (eg, neurologic or central nervous system disturbances), and cisapride can cause serious cardiovascular reactions (eg, torsades de pointes and other ventricular arrhythmias) when taken simultaneously with certain medications.

Disruption of the bezoar can be performed endoscopically. Instruments inserted through the endoscope into the stomach can break the bezoar into smaller pieces, which can pass spontaneously into the small intestine. Some bezoars must be surgically removed. Dissolution with various enzymes (eg, papain, meat tenderizer, cellulase, acetylcysteine) has had variable results. Recurrence can be prevented by repairing any obstruction, correcting dietary routine, or using a prokinetic drug.