Removal Of Bezoar Research Articles

BEZOARS: CLINICAL CHARACTERISTICS, CLASSIFICATION AND MANAGEMENT, A REVIEW ARTICLE

Introduction- The formation of a bezoar is a relatively rare disease entity. Bezoars are mainly of four types depending on their composition: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars. Depending on their location in gastrointestinal tract they are classied intoGastric bezoars which often lead to ulcerative lesions in the stomach and subsequent bleeding, and theSmall intestinal bezoars which usually present with small bowel obstruction. Xray abdomen and USG abdomen are less s Diagnosis – ensitive to diagnose bezoars while GI endoscopy and CT scan abdomen better modalities to make a diagnosis of bezoars. A number of a Management- rticles have emphasized the usefulness of CocaCola administration for the dissolution of phytobezoars. However, persimmon phytobezoars are resistant to such dissolution because of their harder consistency.Cellulase and Papain are used to dissolve bezoars. Endoscopic removal, electro-hydrolytic lithotripsy, argon plasma coagulation are a few newer techniques used. Surgical removal of bezoars, both open and laparoscopically are performed if dissolution methods and endoscopic methods fail. Here we provide an overview of the prevalence, classication, predisposing factors, clinical features,diagnosis and management with review and recent updates

Minimally invasive treatment of duodenal obstruction with acute pancreatitis caused by two large bezoars.

Bezoar without gastrointestinal surgical history occurring simultaneously in the gastric and duodenal lumen is very rare. We report a case of acute pancreatitis due to duodenal obstruction caused by two large bezoars. Two large bezoars were detected in the gastric and duodenal lumen, respectively, on abdominal computed tomography (CT) scan and oesophagogastroduodenoscopy images. Bezoars were crushed and removed using endoscopic devices such as trapezoid basket and lithotripsy handle. After removal of bezoars, blood tests and CT follow-up tests confirmed improvement. In the case of bezoar, which causes duodenal obstruction, it is difficult to administer coke for dissolution, and if it is difficult to perform surgical approach due to old age, an endoscopic treatment using mechanical lithotripsy devices can be an alternative option.

Laparoendoscopic Management of Colonic Trichobezoar Causing Acute Large Bowel Obstruction in an Adolescent Girl

Laparoendoscopic Management of Colonic Trichobezoar Causing Acute Large Bowel Obstruction in an Adolescent Girl

S3546 Urgent Invasive Removal of Bezoar? vs the Disappeared Bezoar

INTRODUCTION: Bezoars are often seen in children and young females with psychiatric disorders, pica, or mental retardations. Clinical presentation of these cases ranges from nausea, vomiting, abdominal pain, to GI bleed, intestinal obstruction/perforations, and even death. Diagnosis with imaging can usually be achieved with CT, EGD, or even US of the abdomen. Treatments involve gastric lavage, dissolution, EGD retrieval, or occasionally surgical removal. Here, we discuss an interesting case of accidentally delayed bezoar removal surgery with unexpected outcomes. CASE DESCRIPTION/METHODS: A 20-year-old female with past history of depression, trichotillomania, emergent-laparotomy (for bezoar removal), presented to the hospital for several months of progressively worsening abdominal pain. She described the pain as cramping, 8/10, radiating from right to left lower quadrant, aggravated by eating and relieved by ibuprofen. Her pain was accompanied by nausea, bloating, and poor appetite. She also reported suicidal thoughts, for which she was placed on 1-to-1 observation for suicidal ideations. CT abdomen showed significant bezoar. The surgeon evaluated the patient and suggested laparoscopy removal. Pt remained symptomatic with abdominal pain for 3 days before she eventually underwent laparoscopy. However, with extensive evaluation by both diagnostic laparoscopy and EGD, bezoar was no longer present. The post-operative period was uneventful. The patient started tolerating diet slowly without complications and was eventually discharged after cleared by a psychiatrist. DISCUSSION: Bezoars are potentially life-threatening problems and require detailed attention. Managements often consist of EGD, surgical procedures, or other invasive procedures. But are these procedures always necessary? It is important to remind ourselves that bezoars can spontaneously resolve/improve without major interventions, thus surgical interventions are not always required. Especially in cases where surgical/procedural intervention is delayed for other reasons, as in our patient, by 3 days. Considering repeating the imaging scan such as an abdominal US or CT, may have possibly prevented this patient from suffering through unnecessary invasive procedures.

A Bezoar Causing Bowel Obstruction After Roux-en-Y Gastric Bypass: A Case Report

Abstract- We aimed to present a patient with phytobezoar causing small bowel obstruction after Roux-en-Y gastric bypass. Thirty-year-old woman with a history of prior Roux-en-Y gastric bypass due to morbid obesity three years ago presented with colicky abdominal pain, distention, nausea, vomiting, and obstipation. Initial abdominal X-ray showed various distended small bowel loops with air-fluid levels. The patient was taken to operation room for laparoscopic exploration, and a phytobezoar was found in distal jejunum. The bezoar was fragmented and flushed through cecum. The patient tolerated the surgery and her symptoms relieved without complication. Moreover, she received dietary consultation in order to prevent future recurrences. Small bowel obstruction in a patient with prior abdominal surgery is mainly caused due to adhesions, stenosis of anastomosis and hernias. An uncommon cause for obstruction is bezoar formation. The majority of patients with bezoars have a history of gastric surgery. Diagnostic imaging is not always helpful, and surgical exploration is sometimes required for diagnosis. Treatment is mainly surgical, but conservative medical treatment is also reported to be helpful. Apart from removal of bezoar, a dietary consultation is required to avoid eating habits leading to bezoar formation. Bariatric surgery is becoming more common; thus its complications are becoming more common as well. Majority of patients with bezoars have a prior history of gastric surgery. Therefore it is important to maintain a high level of suspicion for timely diagnosis of bezoars in patients with prior history of bariatric surgery, especially Roux-en-Y gastric bypass.

1729 An Unusual Case of Ventilatory Compromise and Mega-Esophagus

INTRODUCTION: Mega-esophagus, usually due to achalasia or pseudoachalasia, can cause bronchial compression when filled with phytobezoars. We present a case of mega-esophagus not due to achalasia but with profound ventilatory consequences. CASE DESCRIPTION/METHODS: A 67 year old alcoholic man presented with 24 hours of increasing dyspnea at rest. He denied fevers, chills, cough, chest pain, heartburn, dysphagia, abdominal pain or weight loss. On physical exam he was somnolent but arousable. He was able to speak in full sentences. Lungs revealed right sided rhonchi. He was afebrile, BP 211/100, pulse 68, respiratory rate 18, and O2 saturation 80-85% on room air which improved to 94% after 4L nasal O2. Urine toxicology was positive for opiates and cocaine. Chest CT showed a 6.8 cm esophagus filled with debris. It was herniated into the right upper thorax and terminated in a narrow taper at the aortic arch. The trachea deviated rightward and narrowed to 4 mm. The proximal left main-stem bronchus was narrowed to 2 mm. The right upper lobe showed scarring, cystic bronchiectasis, and pleural thickening. On day 2 the patient developed severe dyspnea and orthopnea. O2 saturation varied with position. After intubation and transfer to the ICU for treatment of acute ventilator failure, GI was consulted to decompress the mega-esophagus presumed due to end stage achalasia. EGD initially revealed a dilated esophagus with a phytobezoar. Upon partial clearing two lumens were noted: one containing more food and one which lead to a normal distal esophagus, stomach, and duodenum. The first opening was a large diverticulum located about 20 cm from the incisors and was filled with recently ingested food. Transfer to a tertiary care center was recommended to manage possible total airway collapse. There, repeat chest CT showed a distended esophagus to the level of the aortic arch with no compression of the airways. Esophagram was not consistent with achalasia but demonstrated a large bezoar filled diverticulum. Repeat EGD was done to complete bezoar removal. Patient’s respiratory status normalized. Elective esophagectomy was planned, but the patient was lost to follow up. DISCUSSION: Our patient likely had a traction diverticulum as he gave no antecedent history of heartburn or dysphagia and the food in the bezoar was not fermented. In addition, his distal esophagus appeared normal on barium swallow. This is may be the first reported case of airway compression due to mega-esophagus due to a traction diverticulum.

Bezoars as a cause of intestinal obstruction. The difficulties of diagnosis

Stomach bezoar is a foreign body in the digestive organ, formed as a result of ingestion and digestion of certain substances that have vegetable, animal or chemical origin. This pathology, rarely found in patients, has another name, that is, gastric concretions. The article presents a clinical case of complex diagnosis and treatment of intestinal obstruction caused by plant bezoar (persimmon). The results of traditional x-ray, ultrasound, MSCT and endoscopic methods are presented. Surgical treatment was carried out: laparotomy, enterotomy, removal of bezoar.

Giant Gastroduodenal Trichobezoar: An Endoscopic Surprise

A trichobezoar is a rare condition, mostly seen in teenage girls with abnormal psychiatric behavior of eating hairs and nails (trichophagia). Trichobezoar may rarely present with nonspecific abdominal symptoms without obvious trichotillomania and trichophagia. Trichobezoar can be complicated with potentially serious conditions such as gastric outlet obstruction, gastric bleeding, intussusceptions, and perforation peritonitis. Conventional laparotomy is method of choice for the removal of trichobezoar. We describe a rare case of giant trichobezoar treated by laparoscopic‑assisted gastrostomy and removal of bezoar. We also reviewed the literature on the current status of endoscopic treatment of trichobezoar.

Successful Emergency Endoscopic Extraction of Gastric Outlet Obstruction Due to Bezoar with Gastric Pneumatosis

Introduction: Gastric pneumatosis (GP) is generally categorized as either emphysematous gastritis (EG) or gastric emphysema (GE). The former has a more ominous presentation, usually requiring a gastrectomy in order to remove necrotic tissue. The breaking and removal of a gastric bezoar causing gastric outlet obstruction (GOO) and subsequent GP is extremely difficult. Here, we present a case of a safe and successful removal of a bezoar with radiologic findings consistent with GP. Presentation Of Case: An 89-year-old man with a history of type 2 diabetes mellitus (DM) presented to our emergency room with a 2-day history of upper abdominal pain, nausea and vomiting. CT scan of the abdomen showed a dilated stomach with significant fluid collection, GOO and GP due to a 42x40 mm mass composed of fat and air densities. Emergency endoscopy revealed two gastric bezoars, one of which was incarcerated in the pyloric region. We used various endoscopic devices to successfully break and remove the bezoar endoscopically. Follow-up endoscopy confirmed that the gastric bezoar had been completely removed.Figure 1Figure 2Figure 3Discussion: Gastric bezoars presenting with GOO are generally too large to extract and too hard to break.There are several reports of bezoars which required surgical removal or dissolution therapy using Coca-Cola.On the other hand, reports of successful endoscopic removal of bezoars presenting with GOO and GP are extremely scarce.In this case, the size of the bezoar (over 40mm) made it necessary to break it using endoscopic snares, forceps and nets. Patient was able to avoid surgery through repeated endoscopic procedures.History of gastrectomy, old age, and type 2 DM are risk factors of phytobezoars which are composed of undigested food.Endoscopic treatment is preferable to surgery not only because it is less invasive, but also because of the possibility of recurrence of post-gastrectomy phytobezoars.GP in this case was believed to be GE, as 1) endoscopy findings showed several gastric ulcers due to mucosal injury arising from intraluminal high pressure resulting from obstruction, 2) the patient was in no apparent distress and 3) CT scan did not show evidence of ischemia. We believe that endoscopic therapy should be attempted before surgery in cases of GE. Conclusion: Endoscopic treatment may be a safe and viable option for the extraction of gastric bezoars presenting with GOO and GP when the patient's condition is stable and there is no evidence of ischemia.

Small Intestine Obstruction in Patients due to Phytobezoar: Case Report of Four Patients

ABSTRACT Introduction: Bezoars are rare cause of small-bowel obstruction and lead to intraluminal obstruction. The other causes are foreign bodies, gall stones, and enteroliths. Phytobezoars are collection of non-digestible materials, usually of vegetable origin, and are most commonly found in patients with impaired gastric emptying, on high-fiber diet and with abnormal food habits.We present a case report of four patients who presented with acute intestinal obstruction, and the etiology in all these four cases was found to be a phytobezoar. The complaints of diffuse pain abdomen, vomiting, and constipation were common in all four cases. One patient had undergone a gastric pull-up surgery for carcinoma esophagus and one female had undergone bilroth1 for peptic ulcer disease. One patient was a known case of diabetes mellitus and had undergone surgery for perforated peptic ulcer few years back. Conclusion: Diagnosis of bezoars is usually confirmed by barium examination or endoscopy, and definitive treatment is surgery in case of obstruction with the removal of bezoar.

The Combination Therapy of Dissolution Using Carbonated Liquid and Endoscopic Procedure for Bezoars: Pragmatical and Clinical Review.

Bezoars are relatively rare foreign bodies of gastrointestinal tract and often cause ileus and ulcerative lesions in the stomach and subsequent bleeding and perforation due to their size and stiffness. Therefore, the removal of bezoars is essential and recent development of devices, the endoscopic removal procedure, is often applied. However, due to their stiffness, simple endoscopic removal failed in not a few cases, and surgical removal has also been used. Recently, the efficacy of a combination therapy of endoscopic procedure and dissolution using carbonated liquid has been reported. To develop the safe and effective removal procedure, we carefully reviewed a total of 55 reported cases in this study including our 3 additional cases, successfully treated with dissolution with endoscopic fragmentation. In summary, the data showed the efficiency in the combination therapy, treating the larger size of bezoar and reducing the length of hospital stay. To the best of our knowledge, this is the largest pragmatical and clinical review for the combination therapy of dissolution and endoscopic treatment for bezoars. This review should help physicians to manage bezoars more efficiently.

Two Cases of Hair Balls in Girls

This article describes two cases of hair balls in girls between aged 2.5 and 12 years. The reason for this quite rare disease may be trichotillomania (compulsive desire to pull out own hair) and trichophagia (compulsive or impulsive desire to pull out, and then to swallow own or someone's hair) typical for Rapunzel syndrome. Initially, the children were enrolled in the Oncology Centre in view of suspected abdominal tumour. After detection of foreign bodies in the stomach, they were transferred to the Department of Clean Surgery. The following surgeries were performed: median laparotomy, gastrotomy on the front wall of the stomach, bezoar removal. Hair balls were dense felt-like conglomerates with a strong offensive odour. Bezoar dimensions of the younger girl were 855, the elder one — 20108 cm. Postoperative period was uneventful. The children were discharged in a satisfactory condition to be followed up by a surgeon, paediatrician, and psychiatrist in their community.

RESULTS OF ENDOSCOPIC REMOVAL OF FOREIGN BODIES AND BEZOARS

Aim. To improve the techniques for treatment of patients with foreign bodies and bezoars in the gastrointestinal tract (GIT). Materials and methods. The results of endoscopic removal of gastrointestinal (GIT) foreign bodies and bezoars in 76 patients aged 3 to 83 years were studied. Fifty two patients swallowed foreign bodies themselves, 12 patients had bezoars, 12 - ligature GIT foreign bodies. Different models of fibroendoscopes (Company Olympus), various methods and instruments for removal of foreign bodies were used. Results. Endoscopic technique appeared to be effective in 12 patients with ligature foreign bodies and in all 52 patients with swallowed foreign bodies (77 subjects were removed). Complete breaking and removal was successfully performed in 9 patients with fitobezoars. Conclusions. Contraindications for endoscopic technique of foreign body and bezoar removal were determined.

Trichobezoar: presenting as primary Intestinal obstruction

ABSTRACTRapunzel syndrome is a rare type of trichobezoar with an extension of the hair into the small bowel. Clinical presentation is deceptive and vague ranging from abdominal mass to gastrointestinal symptoms.Bezoars are usually confined to the stomach which is seen in individuals with psychiatric illness, like trichotillomania, trichophagia and gastric dysmotility. Long standing bezoars may extend into the small intestine leading to a condition known as Rapunzel syndrome. Trichobezoars presenting primarily as intestinal obstruction is very rare. Diagnosis can be established by endoscopy, ultrasonography and computed tomography scan. Treatment includes improvement of general condition and removal of bezoar by laparoscopic approach or laparotomy. Psychiatric consultation is necessary to treat and prevent relapse. We present the case of a 6 years old girl, where the trichobezoar was not suspected at all, especially with negative history of trichophagia and trichotillomania. This girl presented with history of intermittent pain abdomen since 3 months and recent onset severe pain abdomen with abdominal distension and vomiting. Skiagram of abdomen revealed dilated small bowel loops with multiple air fluid levels suggestive of intestinal obstruction. Even ultrasonogram of abdomen was also inconclusive for cause of obstruction. At laparotomy, dilated small bowel loops with multiple interbowel adhesions were seen. A hard mass measuring 5 × 6 cm was seen at distal jejunum causing distal obstruction with pressure necrosis over bowel wall. Enterotomy was done which revealed trichobezoar which was removeden masse. Resection and anastomosis of necrosed jejunum was done. Patient recovered completely after the procedure.How to cite this articleMadhushankar KC, Manjunath K, Saiprasad B, Saishayam M. Trichobezoar: Presenting as Primary Intestinal Obstruction. J Med Sci 2015;1(1):4-6.

Clinical outcomes associated with treatment modalities for gastrointestinal bezoars.

Background/AimsWith technical and instrumental advances, the endoscopic removal of bezoars is now more common than conventional surgical removal. We investigated the clinical outcomes in a patient cohort with gastrointestinal bezoars removed using different treatment modalities.MethodsBetween June 1989 and March 2012, 93 patients with gastrointestinal bezoars underwent endoscopic or surgical procedures at the Asan Medical Center. These patients were divided into endoscopic (n=39) and surgical (n=54) treatment groups in accordance with the initial treatment modality. The clinical feature and outcomes of these two groups were analyzed retrospectively.ResultsThe median follow-up period was 13 months (interquartile range [IQR], 0 to 77 months) in 93 patients with a median age of 60 years (IQR, 50 to 73 years). Among the initial symptoms, abdominal pain was the most common chief complaint (72.1%). The bezoars were commonly located in the stomach (82.1%) in the endoscopic treatment group and in the small bowel (66.7%) in the surgical treatment group. The success rates of endoscopic and surgical treatment were 89.7% and 98.1%, and the complication rates were 12.8% and 33.3%, respectively.ConclusionsEndoscopic removal of a gastrointestinal bezoar is an effective treatment modality; however, surgical removal is needed in some cases.

Rapunzel syndrome: A rare presentation with multiple small intestinal intussusceptions

Bezoars are usually confined to the stomach which is seen in individuals with psychiatric illness like trichotillomania, trichophagia and gastric dysmotility. Long standing bezoars may extend into the small intestine leading to a condition known as Rapunzel syndrome. Diagnosis can be established by endoscopy, ultrasonography and computed tomography scan. Treatment includes improvement of general condition and removal of bezoar by laparoscopic approach or laparotomy. Psychiatric consultation is necessary to treat and prevent relapse. We report a case of Rapunzel syndrome in a 16-year-old girl with trichotillomania. She presented with history of epigastric mass for three months and recent onset of pain abdomen, vomiting and early satiety. Skiagram of abdomen was showing distended stomach and endoscopy revealed trichobezoar. At laparotomy, stomach was distended with trichobezoar and there were multiple small intestinal intussusceptions. Gastrotomy and manual reduction of intussusceptions with the removal of trichobezoar with its tail was done. Patient recovered completely after the procedure.

A safe treatment option for esophageal bezoars

INTRODUCTIONBezoar in the esophagus is a rare condition and associated with structural or functional abnormalities of the esophagus. Endoscopy is the main tool for diagnosis and treatment for bezoar in the esophagus. PRESENTATION OF CASEHere we present a case where an endoscopic evacuation of an esophageal bezoar was unsuccessful. We treated the bezoar through a nasogastric tube using a cocktail composed of pancreatic enzymes dissolved in Coca-Cola. DISCUSSIONEndoscopy is regarded as the mainstay for the diagnosis and treatment of esophageal bezoars. However, when this approach fails, other treatment options include dissolution therapy, and surgical exploration and removal of the bezoar. Surgical removal of an esophageal bezoar is associated with a high risk of morbidity and mortality. We advocate that dissolving therapy should be the first choice of treatment when endoscopic evacuation is not possible. CONCLUSIONThis is the first report describing a successful treatment of an esophageal bezoar with a cocktail of Coca-Cola and pancreatic enzymes. It is an effective, inexpensive, and worldwide available treatment and should be considered when endoscopic evacuation fails.

A Case of Gastric Bezoar Causing Ileal Obstruction During Treatment with Coca-Cola

Gastric bezoars are usually occur in patients who have undergone gastric surgery and have delayed gastric emptying. Recently, the efficacy of nasogastric lavage or endoscopic injection therapy with Coca-Cola has been reported. But the complication like intestinal obstruction has poorly been reported. We report a case of gastric bezoar causing ileal obstruction during treatment with oral administration and endoscopic injection of Coca-Cola. A 53-year-old man was referred because of epigastric pain for a day. He had a history of subtotal gastrectomy with gastroduodenostomy since 8 years ago. On upper gastrointestinal endoscopy, about 6cm sized, dark-greenish hard bezoar was impacted at gastric antrum and about 3-5cm sized three bezoars were found at body. We injected Coca-Cola into the bezoar through the endoscopy and the patient was instructed to drink four liters of Coca-Cola per day. On the 12th day of admission, the patient complained severe abdominal pain. On plain abdominal X-ray and CT scan, small bowel obstruction at proximal ileum with bezoar was suspected and exploration was performed. About 4cm sized two bezoars were impacted at proximal ileum, and small bowel resection with primary closure after removal of bezoar was performed. The patient was discharged on the 10th postoperative day without any complication.

Endoscopic removal of gastric persimmon bezoar-a case report

A 80-year-old man visited our hospital complaining of epigastric pain and vomiting lasting for a week. The upper gastrointestinal endoscopy revealed a gold bezoar about 5 cm in diameter at the greater curvature of the upper body of the stomach associated with multiple ulcers (H1 stage) on the lesser curvature of the antrum. We attempted to remove the bezoar endoscopically using a retrieval net (Model 0071182 USE Group, Olympus Ltd. Tokyo) with success. The bezoar was 5×4×3 cm in size and 7.72g in weight. Compornent analysis with infrared absorption spectrum of the sample detected tannic acid, giving a diagnosis of persimmon bezoar. As gastric bezoar has been reported to be a cause of ulcer due to mechanical stimulation or intestinal obstruction, removal of bezoar should be considered on diagnosis regardless of symptoms. Endoscopic approach using a retrieval net is a safe and effective modality.

Extração de fitobezoar gástrico por videolaparoscopia: considerações técnicas originais

Videolaparoscopic surgery has been used for treatment of almost all surgical abdominal diseases, mainly where there are no large ressections, or operative field is limited. In these situations, laparoscopic surgery has the advantages of less morbidity, quick recovery and good cosmetic results. Bezoars removal, or its mobilization, is probably included in these possible proceedings. Three non-laparotomic procedures were described: 1. endoscopic-laparoscopic; 2. videolaparoscopy and mobilization of intestinal bezoar to the cecum; 3. laparoscopy and gastrotomy for bezoar removal, through suprapubic incision or the umbilical punction. There have been only two publications describing the videolaparoscopic method for bezoar removal, and the methods applied can be complications or morbidity related. We describe one case where the applied technique is simple and easy to perform, time saving and probably less complications-related. This technique, with four trocars, utilized a plastic bag besides the stomach to be opened, followed by gastrotomy, bezoar removal and immediate introduction in the plastic bag, suture of gastrotomy and removal through the left subcostal trocar. This technique was feasible and easy to perform, with short operative time, and there were no intra or post-operative complications; the patient was discharged in the second post-operative day, and is without further problems after one year follow-up. We believe that this could be an adequate technique to perform laparoscopic gastric bezoar removal, and the rigid sequence of operative events allows a quick procedure, with minimal contamination. The videolaparoscopy seems to be an adequate access to surgical treatment of gastro-intestinal bezoars, with or without obstruction, and should be the ellected the procedure of choice to begin the surgical treatment, with convertion to laparotomy in case of any intra-operative adversity.