Gastric Bezoar

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 19/07/2015

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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
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