Bezoar

General Considerations

• Collections of indigestible material found in the gastrointestinal tract, usually the stomach
• From the Persian word “padzahr” which means antidote since they were once used for this purpose
• Incidence is very low
• Risk of trichobezoar (eating of hair) is greater among mentally challenged or emotionally disturbed children
• Also occurs as an occupational disease in brushmakers, blanket weavers and wool workers
• Much more common in females (90%) aged 10 to 19

Etiology

• Chewing on or eating hair or fuzzy materials or indigestible vegetable fiber
• Material unable to exit stomach because of large size
• Gastric outlet obstruction may play a roll
• Poor gastric motility such as might occur in diabetics also may contribute

Predisposition

• Previous gastric surgery such as vagotomy, pyloroplasty, antrectomy or partial gastrectomy
• Inadequate chewing of food
  • Missing teeth, dentures
• Massive overindulgence of food with high fiber contents such as dates or persimmons

Clinical symptoms

• Anorexia
• Bloating
• Early satiety
• History of trichophagy – eating hair
• Trichoptysis – hair may be coughed up
• May be asymptomatic

Phytobezoar (55% of all bezoars):

• Poorly digested vegetable fibers such as
  • Skin and seeds of fruits and vegetables
    • Oranges
    • Persimmons
      • Most common
      • Unripe persimmons contain a chemical “shibuol” that forms a gluelike coagulum after contact with dilute acid in the stomach
• May become impacted in small bowel after forming in stomach

Trichobezoar (hair)

• 80% are < age 30, almost exclusively in females
• Associated with gastric ulcer in 24-70%

Imaging findings

• Upper part of a large bezoar may be visible as a mass with a convex upper border projecting into the gastric air bubble
• An erect abdominal radiograph and a supine radiograph may show a prominent gastric outline with an intragastric mottled mass, outlined by gas in the distended stomach, mimicking a food-filled stomach
• On barium studies, they produce an intraluminal filling defect without attachment to bowel wall
• Interstices of bezoar are filled with barium
• Barium remains in bezoar for hours after exiting remainder of bowel
  • Get delayed film if bezoar is suspected
• Partial or  complete bowel obstruction
• CT
  • Mobile intragastric mass consisting of "compressed concentric rings"
  • A mixed density pattern due to the presence of entrapped air and food debris

Complications

• Pressure necrosis of bowel wall may lead to perforation, peritonitis
• Distal extension of the bezoar can lead to
  • Obstructive jaundice
  • Acute pancreatitis
  • Protein-losing enteropathy
  • Steatorrhea
  • Mechanical small bowel obstruction alone or with perforation

DDx

• Lobulated, villous adenoma
• Leiomyosarcoma

Bezoar. A huge filling defect with barium intermixed in its interstices is seen in the dilated stomach of this patient with a bezoar (blue arrow). The image is from an upper gastrointestinal series.
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Gastric Trichobezoar  - Narinder K Kaushik, Yash P Sharma, Asha Negi, Amal Jaswal: Ind J Radiol Imag 1999; 9 : 3 : 137-139