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Bezoars: from Mystical Charms to Medical and Nutritional Management

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Bezoars: from Mystical Charms to Medical and Nutritional Management NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #13 Series Editor: Carol Rees Parrish, R.D., MS Bezoars: From Mystical Charms to Medical and Nutritional Management Michael K. Sanders Bezoars are retained concretions of undigested foreign material that accumulate and coalesce within the gastrointestinal tract, most commonly in the stomach. Originally described in the stomach of ruminant animals such as goats, antelopes, and llamas, for centuries, bezoars were ascribed mystical and medicinal powers and considered invalu- able possessions. Although the occurrence of bezoar formation has been well docu- mented in humans, the diagnosis, management and treatment remains a difficult task for patients and healthcare professionals. Patients are often asymptomatic or display symptoms indistinguishable from other gastrointestinal disorders resulting in delayed diagnosis and potential life-threatening complications. Individuals may also present with considerable weight loss and compromised nutritional status due to early satiety and recurrent vomiting. Recognition of high-risk individuals and subtle clinical clues may assist in early diagnosis and prompt medical attention. Furthermore, understand- ing the pathophysiology of bezoar formation along with predisposing risk factors may aid in preventing recurrence. INTRODUCTION substance including food, hair, medications, and chew- ezoars are retained concretions of indigestible ing gum. Although they are most commonly found in foreign material that accumulate and conglomer- the stomach, bezoars may occur anywhere from the Bate in the gastrointestinal tract, most commonly in esophagus to the rectum. Depending on a patient’s the stomach. Bezoars can be composed of virtually any course, they may lose a considerable amount of weight due to early satiety and recurrent vomiting. Bezoars Michael K. Sanders, M.D., Gastroenterology Fellow, have been described in patients with normal gastroin- Digestive Health Center of Excellence, University of testinal anatomy and physiology, however the majority Virginia Health System, Charlottesville, VA. of gastric bezoars occur as a complication of previous PRACTICAL GASTROENTEROLOGY • JANUARY 2004 37 Bezoars: From Mystical Charms to Medical and Nutritional Management NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #13 Table 1 the plague. The term bezoar comes Bezoar Classification from either the Persian “pahnzehr” or the Arabic “badzehr,” both of Phytobezoar Composed of nondigestible food particles found in which mean counter-poison or anti- fruit and vegetables (cellulose, hemicellulose, lignin) dote (1,2). Bezoars were considered valuable possessions in the Middle Trichobezoar Hair bezoar. Associated with young females and/or Ages and were commonly set in patients with psychiatric illnesses who ingest hair, gold and decorated with jewelry, carpet, rope, string, etc. given the name “bezoar stone.” Today, bezoars are recognized as a Lactobezoar Compact mass of undigested milk concretions potentially serious medical problem traditionally described in pre-term neonates on highly in patients with compromised gas- concentrated formula tric anatomy and/or gastrointestinal Pharmacobezoar Conglomeration of medications or medication motility. vehicles (extended release products, bulk-forming laxatives) CLASSIFICATION Others Bezoars can be classified into four • Trichophytobezoar Mixture of hair, fruit, and vegetable fibers types based on their origin and • Diospyrobezoar Persimmons components: phytobezoars, tri- • Dead ascaris Worm bezoars chobezoars, lactobezoars, and phar- macobezoars (medication bezoars) (3) (Table 1). Understanding the gastric surgery or altered gastrointestinal motility in classification system may provide further insight into which there is a loss of normal peristaltic activity, treatment options and prevention of recurrence. compromised pyloric function, or reduced gastric acid- Phytobezoars are the most common type of ity. Understanding the pathophysiology of bezoar for- bezoars today. They are composed of food material mation and recognizing high-risk individuals are criti- nondigestible by humans including cellulose, hemicel- cal elements in the diagnosis, management, and pre- lulose, lignin, and fruit tannins (leucoanthocyanins and vention of gastrointestinal bezoars. catechins) (4,5). These nondigestible materials are found in foods such as celery, pumpkins, grape skins, prunes, raisins, and most notably persimmons. Bezoars HISTORY resulting from ingestion of persimmons have been For centuries, bezoars have been described in the commonly described and referred to as diospyrobe- stomach and intestines of humans and ruminants zoars. In high concentrations, fruit tannins may form a including certain goats, sheep, deer, llamas, and coagulum upon exposure to an acidic environment ini- antelopes. The original bezoars came from the stom- tiating the formation of a phytobezoar (6). ach of goats found in the mountains of Western Persia Trichobezoars are the classically described “hair (1). They were introduced to Europe from the Middle bezoar” occurring most frequently in children and East sometime during the 11th century and remained young adult females. Usually observed in individuals popular there as medicinal remedies until the eigh- with psychiatric disorders, trichobezoars result from teenth century. They have been ascribed mystical pow- ingesting large quantities of hair, carpet fibers, rope, ers and employed as medical therapies as early as 1000 string, or clothing (7). The hair fibers become entan- B.C. (2). Considered a panacea for a variety of physi- gled in the gastric folds and resist peristalsis. Undi- cal ailments, they have been used to treat poisons such gested fat and mucus may become trapped in the fibers as arsenic, venomous bites, epilepsy, dysentery, and (continued on page 40) 38 PRACTICAL GASTROENTEROLOGY • JANUARY 2004 Bezoars: From Mystical Charms to Medical and Nutritional Management NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #13 (continued from page 38) and ferment leading to a putrid odor. Gastric acid Although gastrointestinal bezoars are traditionally denatures the hair proteins and blackens the bezoar classified into these four types, other types of bezoars regardless of the intrinsic color. Trichobezoars are usu- have been described including trichophytobezoars (a ally confined to the stomach; however, occasionally mixture of hair, fruit and vegetable fibers), diospy- they have a “tail” which extends through the pylorus robezoars (persimmons), worm bezoars (dead ascaris) and into the proximal small intestine. There have been and an unusual case of a toilet paper bezoar described reported cases of trichobezoars extending throughout in a young girl (19). The components of the bezoar the entire length of the small intestine, known as the often dictate the therapies necessary for removal and “Rapunzel syndrome” (8,9). prevention of recurrence. Lactobezoars are a compact mass of undigested milk concretions located within the gastrointestinal tract. These bezoars have been traditionally associated SYMPTOMS with pre-term infants fed a highly concentrated for- Many patients with bezoars are asymptomatic or pre- mula within the first weeks of life (10). Poor neonatal sent with vague symptoms indistinguishable from gastric motility, dehydration, concentrated formulas, other gastrointestinal disorders. One of the most com- and milk products such as casein have been attributed mon presenting symptoms is a vague feeling of epi- to the formation of lactobezoars (11). However, a gastric discomfort that is present in as many as 80% of recent study suggests that the etiology is likely multi- patients with bezoars (20). Other symptoms include factorial and examples may be seen in a wide range of abdominal bloating, nausea and vomiting, early sati- patients (up to three years of age) who consume breast ety, post-prandial fullness, halitosis, anorexia, dyspha- milk, commercial infant formulas, and cow’s milk gia and weight loss (3). The presenting symptoms may (12). Nevertheless, the preferred initial treatment for provide some insight into the anatomic location of the lactobezoars involves intravenous hydration and tem- bezoar. Esophageal bezoars often present with signs porary cessation of enteral feedings. and symptoms of dysphagia, odynophagia, reflux and Pharmacobezoars are conglomerates of medications retrosternal pain. Bezoars located in the stomach may or medication vehicles in the gastrointestinal tract of result in abdominal pain, nausea and vomiting, gastric individuals at risk for bezoar formation. Several medica- ulcerations from pressure necrosis and subsequent gas- tions have been implicated in causing bezoars including trointestinal bleeding as well as gastric outlet obstruc- cholestyramine, sucralfate, nifedipine, enteric-coated tion. Small bowel bezoars usually present with signs aspirin and antacids such as aluminum hydroxide (13). and symptoms of partial or complete intestinal The majority of case reports describing pharmacobe- obstruction or perforation requiring surgical interven- zoars have involved extended-release products such as tion. Although the sequelae from gastrointestinal nifedipine or verapamil (14,15). The tablet coating is bezoars may be serious and potentially life threaten- composed of cellulose acetate; an indigestible semi-per- ing, most patients present with only vague symptoms meable casing that allows a continuous, controlled indistinguishable from other gastrointestinal disorders. release
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