Gastric Bezoar

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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 Phytobezoar: Undigested vegetable matter

– Persimmons contain tannin, which coagulates on contact with gastric acid
image Trichobezoars: Accumulated, matted mass of hair

– Most common in young girls
image Lactobezoar: Undigested milk concretions (infants)
image Pharmacobezoar: Bezoar composed of medications
image  

IMAGING

• Mobile intraluminal gastric filling defect
• “Mottled” appearance is result of air bubbles retained in interstices of mass
• Large bezoars may fill and take shape of stomach
• Small bezoars are rounded or ovoid

image Tend to float on water-air surface surrounded by gastric contents

PATHOLOGY

• Predisposing causes

image Previous gastric surgery: Vagotomy, pyloroplasty, antrectomy, partial gastrectomy
image Inadequate chewing, missing teeth, dentures
image Overindulgence in foods with high fiber content
image Altered gastric motility: Diabetes, mixed connective tissue disease, hypothyroidism

CLINICAL ISSUES

• Bezoars usually form in stomach

image May fragment and enter small bowel where they absorb water, increase in size, and become impacted
image May present with small-bowel obstruction
• Drinking several liters of cola beverage has been reported to clear all or portions of phytobezoars
• Symptomatic, large phytobezoars or trichobezoars require endoscopic fragmentation or surgical removal

image Spontaneous expulsion of bezoar is uncommon
image
(Left) Film from an upper GI series in a 60-year-old man with early satiety years after vagotomy and Billroth 1 surgery shows evidence of the prior surgery and a large heterogeneous “ball” of debris and gas within the stomach mixed with the barium.

image
(Right) Axial CECT shows a laminated mass image in the stomach due to a phytobezoar.
image
(Left) Upper GI series in a 3-year-old girl with vomiting shows a fixed filling defect in the stomach with a swirled pattern of gas and solid material found to represent a trichobezoar.

image
(Right) A film from a small bowel follow-through shows evidence of a prior Billroth II partial gastrectomy and complete obstruction of antegrade flow of barium in the mid jejunum. At surgery, a phytobezoar was removed, which corresponded to the shape and size of the gastric remnant.

TERMINOLOGY

Definitions

• Intragastric mass composed of accumulated ingested (but not digested) material

IMAGING

General Features

• Best diagnostic clue

image CT or fluoroscopy: Intraluminal mass containing mottled air pattern
• Location

image Sites of impaction: Stomach, jejunum, ileum

– Narrowest portion of small bowel 50-75 cm from ileocecal valve or valve itself
– Any part can be affected, especially in patients with postoperative adhesions
• Morphology

image Large bezoars fill and take shape of stomach

Radiographic Findings

• Radiography

image Abdominal plain film: Soft tissue mass floating in stomach at air-fluid interface

– Mottled radiotransparencies in interstices of solid matter
– ± bowel obstruction
image Insensitive test; bezoar identified in only 10-18% of patients from radiographs alone

Fluoroscopic Findings

• Intraluminal filling defect

image With finely lobulated, villous-like surface
image Freely mobile, without constant site of attachment to bowel wall
• Barium outlines bezoar

image “Mottled” or streaked appearance; contrast medium entering interstices of bezoar
• Filling defect may occasionally appear completely smooth

image Could be mistaken for enormous gas bubble that is freely movable within stomach
• Coiled spring appearance (rare)
• Partial or complete small bowel obstruction

image Try to distinguish obstruction due to postoperative adhesions from bezoar-induced obstruction

CT Findings

• Well-defined, oval, low-density, intraluminal mass

image “Mottled” appearance of mass is due to air bubbles retained in interstices of mass
image Heterogeneous mass without postcontrast enhancement

– Pockets of gas, debris, fluid scattered throughout
– No air-fluid level within lesion
• Large bezoars tend to fill lumen
• Small bezoars are rounded or ovoid; tend to float on water-air surface surrounded by gastric contents

image Oral contrast material may be seen surrounding mass, establishing free intraluminal location
• Bezoar may have “laminated” appearance

Ultrasonographic Findings

• Intraluminal mass with hyperechoic arc-like surface

image With marked acoustic shadowing
• Identification of additional intestinal or gastric bezoars may be difficult

Imaging Recommendations

• Best imaging tool

image CT: More accurate in confirming diagnosis of gastric bezoar suggested by other modalities

– Diagnose bezoar-induced bowel obstruction
– Detect additional gastric or small-bowel bezoars
• Protocol advice

image May go undetected if CT scan viewed at routine abdominal soft tissue window and level settings

– Modifying window setting by reducing level to -100 HU makes it possible to better identify

DIFFERENTIAL DIAGNOSIS

Gastric Carcinoma

• Filling defect in stomach; polypoid or fungating
• Lesion on dependent or posterior wall seen as filling defect in barium pool
• Wall thickening, ulceration, irregular narrowing and rigidity, amputation of folds, stenosis

Postprandial Food

• Fluoroscopy: Intraluminal filling defect
• Occasionally difficult to differentiate bezoar from large amount of retained food

image Food usually less mass-like
image CT: Bezoar shows lower density than food particles

Intramural Mass

• Stromal tumor (GIST), lymphoma, melanoma metastases

image Lobulated or polypoid filling defects arising from gastric wall
image Infiltration of gastric wall; mucosal thinning or ulceration, submucosal mass

PATHOLOGY

General Features

• Etiology

image Ingested material unable to exit stomach

– Accumulated due to large size, indigestibility, gastric outlet obstruction, poor gastric motility
image Phytobezoar: Unripe persimmons, oranges

– Persimmons contain tannin, which coagulates on contact with gastric acid
– Glue-like coagulum forms, trapping seeds, skin, etc.
image Trichobezoars: Accumulated, matted mass of hair

– Most common in girls who chew on ends of their hair
image Medications reported to cause bezoars

– Aluminum hydroxide gel, enteric-coated aspirin, sucralfate, guar gum, cholestyramine
– Enteral feeding formulas, psyllium preparations, nifedipine XL, meprobamate
• Associated abnormalities

image Peptic ulcer: High incidence, especially with more abrasive phytobezoars

– Trichobezoars associated with gastric ulcer in 24-70%
image Concurrent gastric bezoar found in 17-53% of patients with small-bowel bezoar
• Predisposing causes

image Previous gastric surgery: Vagotomy, pyloroplasty, antrectomy, partial gastrectomy
image Inadequate chewing, missing teeth, dentures
image Overindulgence in foods with high fiber content
image Altered gastric motility: Diabetes, mixed connective tissue disease, hypothyroidism

Gross Pathologic & Surgical Features

• Conglomerates of food or fiber in alimentary tract
• Hairball

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Asymptomatic; incidentally found on imaging
image Anorexia, bloating, early satiety
image Crampy epigastric pain
image Sense of dragging, heaviness in upper abdomen
image With large bezoars, symptoms of pyloric obstruction

– Can clinically simulate gastric carcinoma
image May present with small bowel obstruction
image Trichotillomania: Impulse disorder to pull out hair from scalp, eyelashes, eyebrows, other parts of body

– Gastric trichobezoar may result in failure to gain weight
– Iron deficiency anemia, painless epigastric mass
• Clinical profile

image History of recent ingestion of pulpy foods
image History of previous gastric surgery
image Physical examination: Bald patches on patient’s head or bald sibling with trichobezoar
• In adults, bezoars are most frequently encountered after gastric operation

image In children, associated with pica, mental retardation, coexistent psychiatric disorders
• Trichobezoars seen especially in those with schizophrenia or other mental instability

image Primarily girls who chew and swallow their own hair
• Lactobezoar most often found in infants

image Preterm infants on calorie-dense formulas
image Immature mechanism of gastric emptying

Demographics

• Age

image Trichobezoar: 80% < 30 years old
• Gender

image Trichobezoars occur predominantly in females
• Epidemiology

image Incidence: 0.4% (large endoscopic series)
image Phytobezoar: 55% of all bezoars
image Phytobezoar responsible for 0.4-4% of all intestinal obstructions

Natural History & Prognosis

• Bezoars of any type most often occur in background of altered motility or anatomy of gastrointestinal tract
• Bezoars usually form in stomach

image May fragment and enter small bowel where they absorb water, increase in size, and become impacted
• Bezoars are uncommon cause of acute gastric outlet obstruction
• Trichobezoar: Can enlarge to occupy entire lumen of stomach assuming shape of organ

image Trichobezoars do not usually migrate toward small bowel
• Rapunzel syndrome, found characteristically in girls with varying gastrointestinal symptoms

image Rare form of gastric trichobezoar extending throughout bowel
image Possessing “tail” which extends to or beyond ileocecal valve, causing intestinal obstruction
image High comorbidity of serious pediatric psychiatric disorders
• Complications: Ulceration and pressure necrosis of bowel wall, perforation, peritonitis

image Bleeding, obstructive jaundice, intussusception, and appendicitis

Treatment

• Endoscopic lavage fragmentation and extraction is safe and effective
• Drinking several liters of cola beverage

image Has cleared some or all of phytobezoars
• Symptomatic, large phytobezoars or trichobezoars require endoscopic fragmentation or surgical removal
• Diagnosis of bezoar as cause of obstruction important

image Modifies approach to treatment; accelerating use of surgery
image Bezoar-induced bowel obstruction rarely improves with conservative treatment
image Early surgery required to secure definitive solution
• 9% of patients may require 2nd operation

image Recurrent bowel obstruction caused by presence of residual bezoar
• Spontaneous expulsion of bezoar is uncommon

DIAGNOSTIC CHECKLIST

Consider

• Bezoar formation may be more common than previously thought

image High index of suspicion could help avoid costly evaluations for obstructive symptoms
• When intestinal bezoar is diagnosed, consider concomitant gastric bezoar
• Discrepancy between CT and surgical localization

image May be caused by migration of bezoar during interval between imaging and surgery
image
Double-contrast view shows barium collecting within the interstices image of the bezoar. Prior gastric surgery is a predisposing factor for developing a bezoar.

image
Upper GI series in a patient with Billroth 1 type partial gastrectomy shows a bezoar image in the stomach.
image
Supine film from an upper GI series shows that the mottled mass image corresponds to the shape of the stomach.
image
Film from an upper GI series in a young woman with diabetes shows persistent filling defects image within the stomach that conform to the shape of the stomach. Notice that the rounded top of the mass is floating within the stomach.
image
The surgical clips image from a vagotomy and the antrectomy with duodenal anastomosis (Billroth 1 procedure) are shown in a middle-aged man with phytobezoar. There is a solid mass image with a gastric shape composed of gas and undigested plant material.
image
A more lateral view from the upper GI series better shows the vagotomy clips image as well as the bezoar.
image
Phytobezoar in a patient with prior Billroth 2 procedure is shown. Note the evidence of prior surgery, including the gastroenterostomy image. The bezoar image is the fixed filling defect within the stomach.
image
Upper GI series shows stasis of the barium in the stomach (after a 20-minute delay), indicating delayed gastric emptying. There is a large filling defect within the stomach that conforms to the shape of the stomach: A gastric bezoar. This may be difficult to distinguish from retained food.

SELECTED REFERENCES

1. Altintoprak, F, et al. CT findings of patients with small bowel obstruction due to bezoar: a descriptive study. ScientificWorldJournal. 2013; 2013:298392.

2. Tudor, EC, et al. Laparoscopic-assisted removal of gastric trichobezoar; a novel technique to reduce operative complications and time. J Pediatr Surg. 2013; 48(3):e13–e15.

3. Zildzic, M, et al. The large gastric trichobezoar associated with ulcers and antral polyposis: case report. Med Arch. 2013; 67(3):212–214.

4. Dirican, A, et al. Surgical treatment of phytobezoars causes acute small intestinal obstruction. Bratisl Lek Listy. 2009; 110(3):158–161.

 

Gonuguntla, V, et al. Rapunzel Syndrome: A Comprehensive Review of an Unusual Case of Trichobezoar. Clin Med Res. 2009. [Epub ahead of print].

Lee, BJ, et al. How good is cola for dissolution of gastric phytobezoars? World J Gastroenterol. 2009; 15(18):2265–2269.

Vargas, JD, et al. A perfect storm. Gastric bezoar. Am J Med. 2009; 122(6):519–521.

DuBose, TM, 5th., et al. Lactobezoars: a patient series and literature review. Clin Pediatr (Phila). 2001; 40(11):603–606.

Ripolles, T, et al. Gastrointestinal bezoars: sonographic and CT characteristics. AJR Am J Roentgenol. 2001; 177(1):65–69.

Morris, B, et al. An intragastric trichobezoar: computerised tomographic appearance. J Postgrad Med. 2000; 46(2):94–95.

Gayer, G, et al. Bezoars in the stomach and small bowel—CT appearance. Clin Radiol. 1999; 54(4):228–232.

Phillips, MR, et al. Gastric trichobezoar: case report and literature review. Mayo Clin Proc. 1998; 73(7):653–656.

West, WM, et al. CT appearances of the Rapunzel syndrome: an unusual form of bezoar and gastrointestinal obstruction. Pediatr Radiol. 1998; 28(5):315–316.

Newman, B, et al. Gastric trichobezoars—sonographic and computed tomographic appearance. Pediatr Radiol. 1990; 20(7):526–527.

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