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BEZOARS

ASN KISHAN*, NK KADLI+, BG PONNAPPA*, M PAUL KORATH**, K JAGADEESAN***
*Surgical Registrar; **Chief Physician; ***Professor of Surgery, Director, KJ Hospital, Chennai - 600084; +Professor and HOD of Pediatric Surgery, JJM Medical College, Davangere, Karnataka.

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INTRODUCTION

There are few topics in the history of medicine that are more bizarre and mystical than subject of bezoars. The term bezoar, is believed to be derived from the Arabic ‘Badzehr‘, Persian ‘Padzahr‘ or Turkish word ‘Panzehir‘, all meaning counter poison or an antidote. Bezoars, in medicine are concretions of various foreign or intrinsic substances that have been found in the gastrointestinal tract of human and animals. [1-5]

In the past bezoars were isolated from the gastrointestinal tract that certain goats, sheep and gazelles and preserved to be used as medical charms. This has been documented as early as 1000 BC. [4] They were used for the treatment of ailments like snake bites, old age, plagues, and evil spirits as it was believed that bezoars had healing powers.5 So precious were they that a gold-framed bezoar was included in the inventory of Queen Elizabeth’s crown jewels in 1962. Proper dosage of these animal concretions was as much a problem as was the establishment of clinical indications: "...for one bitten, poisoned, or stung, is the weight of 12 barley grains; the dose for weakness of the heart and loss of sexual power is one grain". [5]

DeBakey and Ochsner, in a comprehensive review of published reports up to 1938, collected 303 recorded cases (Table 1). Tondrean and Kirkiln found 100 additional cases during the ensuing 12 years. [1] We present our series of bezoars here and also a brief literature review till date.

MATERIAL AND METHODS

A total of 15 cases were studied over a period of 11 years (Jan. 1989 - Oct. 2000). The male:female was 1:14 and the age ranged form 5-20 (median 12.5). Four patients diagnosed as having a bezoar refused admission and treatment and thus were excluded from the study. All the cases were followed up for an average period of four years (3.93) and no recurrences were found.

The most common mode of presentation was that of pain abdomen and weight loss, which was present in all the 15 cases. Thirteen patients had mass abdomen and 10 patients had dysphagia. The other symptoms were, nausea and vomiting, [14] weakness,[13] anorexia,[13] malaise, [7] foul breath, [6] diarrhoea [3] and constipation [5]. Two patients had alternating constipation and diarrhoea.

TABLE 1 Showing the different studies and their findings [1]
Study by	Cases	Year	Age	Female%
DeBakey and Ochsner	303	Upto 1938	> 80% were < 30 year	> 90%
Falk	30	1937-67	-	-
Maingot	8	1979-1982	2-17	100%

All the patients were subjected to routine blood and urine investigations and when required organ specific investigation. All the 15 cases had anaemia, and 13 had mild leucocytosis, the rest of the investigations were found to be within normal limits. Ultrasound abdomen showed a mass in the stomach, barium meal showed typical features of trichobezoar. Upper GI endoscopy was diagnostic.

There were 13 cases of Trichobezoar and one Phytobezoar and one case of Concretion. Of the Trichobezoar one case was that of ‘Rapunzel Syndrome‘. Surgery was the main form of treatment employed in all the cases. The average stay in the hospital postoperatively was eight days. A 15 year old patient who had emergency laparotomy for trichobezoar obstructing the ileum in whom about 40 cms of terminal Ileum was resected as it was non-viable and hence, died on the fifth postoperative day due to septicaemia.

DISCUSSION

Though diagnosis of a bezoar is a rarity in clinical practice, its bizarre occurrence arouses everybody’s interest. The bezoars are always associated with some form of psychiatric or psychological behavioural problem, and pose a difficult problem to treat. Based upon their composition bezoars have been further classified into four subtypes [1-4 , 7] viz.-Phytobezoar, Trichobezoar, Medication bezoar and Concretion (Table 2).

TABLE 2 Showing the classification and composition of bezoars[ 8-10]
	Types	Composition
1.	Phytobezoar Diospyrobezoar Harapanahalli bezoar	Vegetable matter Persimmon fiber Vegetable matter (poison?)
2.	Trichobezoar	Hair
3.	Pharmacobezoar	Tablets/semi-liquid masses of drugs
4.	Concretions	Furniture polish, paint, stones, pebbles and sand etc.

Phytobezoars

This comes from a Greek prefix ‘phyto‘ (plant). The most common form of phytobezoar comprising about 3/4 of the cases is due to ingestion of ‘persimmons‘.[1] Persimmon (botanical name - diospyros kaki linn hence the name ‘diospyrobezoar‘) is a fruit grown mainly in Japan and mainland Asia; it is of two types one with a very astringent taste and cannot be eaten until it is soft ripe and those that produce non astringent fruits and can be eaten crisp or soft. [11] Persimmon contains large amount of ‘shibuol‘ a phlobatanin, which is coagulated by gastric acid into a form that efficiently bonds vegetable fibres, seeds, and pieces of skin together. Ingestion of unripe persimmons, especially when the stomach contains little or no food matter to interfere with the contact and aggregation of the seeds and fragments of skin, predisposes to development of this type of bezoar. Genip fruit is also prone to accumulate in the stomach.[1 , 8]

Non-persimmon phytobezoars have demonstrated the presence of tannin monomers, which are probably polymerized in the stomach to form the necessary glue for bonding the vegetables. Other reason for the formation of bezoar is believed essentially to be mechanical and depend on the insoluble and indigestible fibre content. The non-persimmon phytobezoars may also be caused by ingestion of other vegetable matter, such as coconut fibres, heather roots, celery fibres, pumpkin skins, stems of grapes, prunes, raisins, salsify, leek, marrow, wild beets, and couch grass. In the older times cimetidine was considered a possible factor in the development of bezoars by decreasing the digestive action in the stomach; though it has not been proven. [1 , 8]

These masses vary considerably in shape and size, being ovoid, cylindrical, oblong or pyramidal and ranging from 5-10 cm long and 3-6 cm wide. They are usually dark brown or black with a smooth, attrite or bossilated, pitted surface. Although firm and compact when freshly removed they tend to be friable and crumble early after drying. On section they are found to be composed of an amorphous gummy material interspersed with cellulose fibres and occasionally seeds and skin.

Postgastrectomy Bezoar

In the late 1930’s none of the reported patientswith bezoar had prior gastric surgery. The literature of the past years contains many reports, which describe phytobezoars complicating the postoperative management of patients with gastric stasis and hypochlorhydria following Billroth I and Billroth II partial gastrectomies, especially when accompanied by vagotomy. Attesting to the role of vagotomy in predisposing to bezoars, an interesting report described a large gastric bezoar in an autovagotomized patient, the neurolysis being secondary to encasement of the vagi by oesophageal carcinoma. Factors which presumably are causally related to bezoar impaction in the small bowel include the amount of indigestible material in the bezoar (pulpy, fibrous fruit or vegetables, especially oranges), the condition of the chewing mechanism, the caliber of the small bowel (diameter is smallest at a site 50 to 75 cm proximal to the ileocaecal valve), and the loss of pyloric function limiting the size of food particles entering the duodenum. [5]

Harapanahalli Bezoar

In addition to the above-mentioned phytobezoars; this one needs a special mention for its uniqueness. This kind of bezoar is caused by a pill said to be made from the blood of a species of chameleon in combination with certain East Indian drugs. This was used by a certain Brahmin widows of the Western Taluks of Bellary District (Pre-independence Madras Presidency, prior to the formation of Mysore State, which was later named as Karnataka) to cause the slow decline and death of strangers who happened to share their table. There is a superstition among them that this mode of doing away with young and energetic men, mostly executive officials paves the way for their salvation. Whatever the object might be, the bolus of food in which it is administered forms the Bezoar, with the minute pill as the nucleus, and the food around never gets digested. This is proven by the fat that even after six months the vomited bezoar, if it fortunately occurs, contains the very food in which it was administered originally. This kind of Bezoar acts in the same manner as all the others and causes symptoms akin to them.

The pain and uneasiness in the epigastrium begins about a fortnight after the administration. Intense gastritis and active dyspepsia set in. There is some accompanying fever also, and the patient ultimately dies of slow inanition in three to six months. Though this Bezoar is comparatively small, it does not come out in the vomit, nor does it pass the pyloric sphincter. The horrible practice has by all practicable means become extinct.

The few patients who survived the ordeal with the help of prompt and proper treatment gave the above history. This treatment consists in giving a green shrub internally, found in those parts; and this acts by bringing the Bezoar along with the vomit or allowing it to pass through the pylorus and be discharged in the faeces. But it is indeed fortunate for the stranger that this is a bygone practice at present.

This pill is said to have been originated at Harapanahalli, the intellectual centre of that district and goes by the same name; and hence the name. At present this place is a taluk in the Davangere District in the state of Karnataka India. [9,10]

Trichobezoars : (Pilobezoar)

As the term implies it consists of a large quantity of hair of varying length, firmly matted together, when fully developed forms a perfect cast of stomach and even a part of duodenum. Mixed with this hair may be various filamentous substances and other stringy materials besides the patient’s hair; such as cotton or wool thread, string, bristles, vegetable fibres and animal hair. Usually the mass is dark greenish brown or black with a glairy, slimy surface and extremely nauseating odour presumably caused by fermentation, decomposition and putrefaction of the various food and organic residue intimately interspersed in the hair. [1] (Fig 1)

Fig 1 : Trichobezoar

Rapunzel Syndrome

Vaughan and associates coined this term in 1968, for an unusual manifestation of trichobezoar in which the mass extends from stomach and duodenum through a large portion of the small intestine (Fig. 2).

Fig 2 : Rapunzel syndrome

Although trichobezoar develops primarily from habitual ingestion of hair, the precise cause is not clearly understood. Whereas only 9% of patients with trichobezoar show overt psychic/mental disturbance it is generally believed that trichophagy; like other habitual body manipulations; such as nail biting, toe biting and thumb sucking, represents an expression of personality maladjustment.

Medication Bezoars : (Pharmacobezoar)

There has been increasing concern about the development of medication bezoars resulting from aluminium hydroxide gel as well as polysterene sodium sulphonate as used in intestinal exchange resin. Symptoms of intestinal obstruction have been reported most frequently. Bezoars causing intestinal obstruction have also been reported from the administration of isocal. Rosenberg reported an antacid bezoar in the stomach of a premature infant who was treated conservatively. The largest series is by Grosfeld and associates, who reported 27 neonates with gastric lactobezoars, three of whom had perforations. These studies indicate that most GI bezoars in infants are related to therapy.

Medications associated with bezoar formation

A well established example of pharmacobezoars is that of enteric-coated aspirin tablets (ECASA). Baum reviewed six cases of ECASA accumulation in the stomachs of patients and the characteristic feature shared by all six patients was the presence of gastric obstruction. [12] The treatment is gastric lavage with NaHCO3 in order to dissolve the enteric coat followed by aspiration of the gastric contents. [13] The problem of bezoar has not been seen with regular aspirin tablets. [12]

There have been case reports linking antacids, sucralfate, bulk laxatives (e.g. pysllium), cholestyramine, iron and meprobamate in pharmacobezoar formation. [7, 14-19] However sustained release medications capable of bezoar formation are of concern from an overdose standpoint. Pharmacobezoar formation has been reported in sustained release preparations of nifedipine, theophylline and verapamil. [7, 20-26]

Concretions

Concretions are relatively unusual forms of bezoars, representing less than 5% of reported cases. They usually result from the imbibition by painters or furniture workers of furniture polish, which consists mainly of a strong solution of shellac. Drinking water after its ingestion precipitates the resin into an accumulated mass, and the constantrepetition of this process result in formation of large concretions. Most rarely, concretions have occurred from ingestion of certain medicaments such as bismuth carbonate (in a patient who was given bismuth carbonate as a contrast media for X-ray examination), salol (taken for treatment of cystitis), magnesium and sodium carbonate (for peptic ulcers), and paraffin (derived from a laxative preparation). [1] The other rarer forms of concertion are formed in children swallowing sand, stones, pebbles, etc.

Clinical Manifestations

Bezoars may produce symptoms ranging from a dragging or fullness in the upper quadrants to epigastic pain, which is the most frequent symptom (70%). Periodic attacks of nausea and vomiting (64%) are also common. A mass can be palpated in 57% of phytobezoars, as contrasted with 88% of trichobezoars. Gastric outlet and intestinal obstruction are also common. The incidence of associated peptic ulceration with the more abrasive phytobezoars (24%) is greater than with trichobezoars (10%). The incidence of perforation and peritonitis is about seven and 10 per cent. [ 1 , 5]

The characteristic symptoms of trichobezoars are pain, nausea, vomiting, anorexia, dyspepsia, malaise, weakness, loss of weight, and a sense of weightily oppression in the epigastrium, usually of insidious onset. The most characteristic physical finding is a large, readily, palpable and freely movable abdominal mass, usually located in the epigastrium but sometimes occupying lower positions, with a well-defined, smooth outer surface and uniform firmness. In cases of phytobezoar, particularly diospyrobezoar, a history of ingestion of persimmon can be elicited.

A history of furniture polish imbibition, particularly in painters of furniture workers, may be obtained in cases of shellac concretions.

Investigations

Most patients with bezoars have slight secondary anaemia and mild leucocytosis. Gastric analysis and faecal examinations, particularly in trichobezoars, sometimes reveal strands of hair. Gastric acidity tends to be normal or low in patients with trichobezoars and normal or high in those with phytobezoars.

Trichobezoars can be diagnosed using ultrasound, especially if the patient is given clear fluid, which helps to outline the mass. Air tends to be trapped in and around the hair fibres, which cause a characteristic area of echogenicity that obscures the mass but conforms to the shape of distended stomach. It may also produce shadowing intraluminal densities on the sonogram. [27]

The most useful diagnostic procedures are roentgenography and gastroscopy. Typically, fluoroscopic examination with the patient in the erect position shows the swallowed barium held up in the cardiac end of the stomach for a few seconds as though "forming a cap to something inside the organ" then suddenly diffusing slowly downward on either side of a non-opaque foreign body, following the regular contours of the greater and lesser curvatures to map out the normal contour of the stomach. After six hours, most of the barium having passed out outlines the mass in the stomach in a lace-like pattern (Fig. 3). Insufflation of the stomach with air may also aid in demonstrating the intragastric character of the foreign body.

Fig 3 : Barium meal showing Trichobezoar

Gastroscopy, however, remains the best technique to diagnose and classify bezoars. Trichobezoars are black and tarry, whereas most phytobezoars vary in colour from yellow to brown to green. Endoscopic biopsy yielding hair or vegetable fibres is pathognomonic. [5]

The complications of bezoars include obstruction, ulceration, haemorrhage, perforation, and peritonitis. The most frequent complication is intestinal obstruction, occurring in about 10 per cent of patients with trichobezoars and about 25 per cent of those with phytobezoars. The higher incidence of obstruction in patients with phytobezoars is probably due to the fact that they are more likely to be multiple and of harder consistency. Gastroduodenal ulceration occurs only slightly less often than intestinal obstruction. The characteristics of these ulcers are similar to those of peptic ulcers.

Treatment

The treatment of large bezoars and concretions is essentially surgical. Proper preoperative preparation is important, especially in patients with long-standing bezoars associated with inanition, dehydration, and anaemia. The gastric incision should be made on the anterior wall of the stomach at right angles to its longitudinal axis. Because trichobezoars often extend through the pylorus well into the duodenum, special care should be taken to ensure extraction of the entire mass.

In case of associated simple ulcers, removal of the foreign body is usually sufficient. In the presence of complications of the ulcer, such as haemorrhage, perforation or penetration, or stenosis, appropriate supportive and surgical measures are indicated. Interest has increased in the use of non-operative means for the elimination of small bezoars comprised primarily of food. Among these is the ingestion of meat tenderizers. The indiscriminate use of these agents may significantly delay proper surgical treatment. Small bezoars may be fragmented through the gastroscope. Often, fragmentation can be accomplished in a single treatment, but in other instances, two to three gastroscopic treatments administered two to three days apart will be necessary.

Recent Advances in Treatment

After the first gastroscopic removal of a bezoar by McKechne 1972, different endoscopic methods have been reported including a water jet, forceps, snare, and a basket. Huge and solid bezoars, however are still a problem. For these solid bezoars the use of a modified needle-knife (bezotome) and a modified lithotripter (bezotriptor) has proven very successful. The bezotome is used for trichobezoars and the bezotriptor is used for persimmon bezoars. [29,30] For persimmon bezoar electrohydraulic lithotripsy has also been tried successfully. [28] The other method that has been tried successfully in treatment of phytobezoar is cellulose, wherein complete dissolution has been observed. [29]

The standard treatment of postgastrectomy phytobezoar includes manual attempts at external disruption, a liquid diet, suction and lavage, and endoscopic internal fragmentation using biopsy forceps and polypectomy snares. Madsen and coworkers successfully used the Teledyne Water Pik to disrupt phytobezoars rapidly in five patients. They recommended this method as a first-line approach.

CONCLUSION

Bezoars are a bizzare medical problem, though the incidence is low. It has been our effort to point out the clinicopathological manifestation of bezoars, and their management in this series of 15 cases collected over 11 years. The disease is a physical manifestation of a psychological problem and common in young female patients. The problem of trichobezoar and concretion will not disappear until the underlying psychiatric and psychological problems are dealt with promptly. Persimmon fruit which is available in the market should be consumed with great caution. As for the medical bezoar are concerned the medications should come with a warning about misuse of the drug.

ACKNOWLEDGEMENTS

This article will be incomplete if I do not acknowledge the effort of Dr. NK Kadli Professor and HOD of Pediatric Surgery, JJM Medical College, Davangere, Karnataka, India. My sincere and heartfelt thanks to him for guiding us. We also would like to thank our junior colleague. Dr. Vishwanath Hanchanale final year surgical postgraduate of JJM Medical College, for helping us prepare this paper with great enthusiasm.

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