A Single-center 12-year Experience of Patients with Gastrointestinal Bezoars

By -

 

Executive Summary

Gastrointestinal (GI) bezoars—concretions of indigestible material—represent a relatively rare but clinically significant challenge, particularly in elderly populations and those with prior abdominal surgeries. This report synthesizes findings from a 12-year study of 75 patients, highlighting that while the stomach and small intestine are the most frequent sites for bezoar formation, treatment outcomes vary drastically based on location.

Key findings indicate that phytobezoars (composed of food fibers) account for 96% of cases. Non-surgical management, including chemical dissolution with Coca-Cola® and endoscopic intervention, is highly effective for esophageal and gastric bezoars (89% success rate for the latter). However, bezoars located in the small intestine frequently result in ileus (87.9% of cases) and often necessitate surgical intervention (60.6%). Successful management depends on a multidisciplinary approach that prioritizes fluid and electrolyte correction alongside targeted removal techniques.

Patient Demographics and Risk Factors

The study population exhibits specific demographic trends and underlying health profiles that predispose individuals to bezoar formation.

  • Age and Gender: The mean age of patients was 71.2 years, with a nearly even distribution between males (38) and females (37). Over 80% of the study population was aged 65 or older.

  • Medical History: Common comorbidities include:

    • Hypertension: 44%

    • Diabetes Mellitus: 30% (noted as a predisposing factor for gastric bezoars).

    • Prior Surgery: 42.6% of patients had a history of intra-abdominal surgery, with 30.7% specifically having undergone gastric surgery.

  • Medication and Performance: A small percentage of patients used analgesics (9%), tricyclic antidepressants (5%), or SSRIs (2.6%). The mean WHO/ECOG Performance Status Scale score was 1.8.

Characteristics and Classification of Bezoars

Bezoars are primarily classified by their composition and their anatomical location within the GI tract.

Composition

  • Phytobezoars: The overwhelming majority (96%) were identified as phytobezoars, which consist of indigestible vegetable or fruit fibers.

  • Other: 4% were of unknown composition; notably, no trichobezoars (hair-based) were recorded in this study.

  • Dimensions: The mean longitudinal diameter was 51.7 mm, with a transverse diameter of 44.2 mm.

Anatomical Distribution

The location of the bezoar dictates the severity of symptoms and the likely treatment path:

  • Stomach: 44%

  • Small Intestine: 44%

  • Duodenum: 12%

  • Esophagus: 2.6%

Management and Treatment Modalities

Management strategies are categorized into conservative, chemical, endoscopic, and surgical approaches.

1. Conservative and Chemical Management

Initial treatment focuses on correcting physiological imbalances:

  • Hydration: Correction of volume status and electrolytes (e.g., hypernatremia or hypokalemia) via intravenous fluids (50–100 mL/hour).

  • Chemical Dissolution: The use of Coca-Cola® (via oral intake or nasogastric lavage) and proteolytic enzymes (e.g., Pancreatin/Norzyme) to break down the bezoar.

  • Spontaneous Resolution: Approximately 20% of gastric bezoars resolved spontaneously with only NPO (nothing by mouth) status and hydration.

2. Endoscopic Removal

Utilized primarily for upper GI bezoars, this involves fragmentation and extraction using a single-channel endoscope. Tools include:

  • Rat-tooth or alligator-jaw grasping forceps.

  • Snares, baskets, and retrieval nets.

  • Argon plasma coagulation (APC) or specialized knives for fragmentation.

3. Surgical Intervention

Surgery is reserved for cases where non-surgical methods fail or where there is a mechanical obstruction:

  • Procedures: Open ileostomy, enterostomy with primary repair, or segmental resection in cases of ischemia or perforation.

  • Small Bowel Necessity: Surgery was required for 60.6% of patients with small intestinal bezoars due to the high incidence of ileus.

Clinical Outcomes by Location

Esophageal Bezoars

While rare, these occur in patients with motor disorders or prior surgeries (e.g., total gastrectomy).

  • Success Rate: 100% success with non-surgical management.

  • Note: Recurrence was observed in one patient after six months. Clinicians must weigh the risk of aspiration before initiating chemical dissolution in the esophagus.

Gastric Bezoars

Frequently associated with gastric ulcers (63.6%), primarily in the antrum, likely due to pressure necrosis.

  • Success Rate: 26 out of 33 patients (approx. 79%) were managed non-surgically.

  • Endoscopic Success: 89% in patients where it was attempted.

  • Risk: Crushed fragments of gastric bezoars may migrate distally, causing a secondary small bowel obstruction.

Duodenal and Small Intestinal Bezoars

  • Duodenum: Nine cases were identified; 77% were successfully treated without surgery, often requiring multiple endoscopic sessions.

  • Small Intestine: These cases are the most critical. 87.9% presented with ileus.

  • Outcome: Only 39.4% could be managed conservatively; the majority required surgical removal.

Conclusions and Clinical Insights

The study concludes that the management of GI bezoars must be tailored to the anatomical site.

  • Upper GI (Esophagus/Stomach): Should be addressed first with conservative and endoscopic methods. Endoscopic techniques have evolved to the point where they can often replace surgery.

  • Lower GI (Small Bowel): Carries a high risk of obstruction (ileus) and ischemia, making surgical intervention the standard of care in more than half of these cases.

  • Multidisciplinary Necessity: Treatment success relies on a combination of electrolyte correction, chemical dissolution, and skilled endoscopic or surgical intervention. Professional consensus emphasizes the importance of managing dehydration and metabolic imbalances before proceeding with invasive removal.