Gastrointestinal bezoars: Review of the literature and report of a rare case of pumpkin seed rectal impaction

In science, bezoar is a mass of hair or undigested vegetable matter, found in a human or animal's intestines, similar to a hairball. Usually, it is found trapped in every part of the gastrointestinal system and must be distinguished by pseudobezoar which is an indigestive object voluntarily introduced into the digestive tract. The term Bezoar is from Arabic bāzahr, "bezoar" or ultimately from Middle Persian p'tzhl pādzahr, "antidote, bezoar"ægagropile o egagropile It should be a universal antidote that works against any poison, and could neutralize any poison. Otherwise, the name could derive from a kind of Turkish goat whose name is just bezoar. Authors report a case of fecal impaction by pumpkin seeds bezoar with abdominal pain: a difficulty to void with subsequent rectal inflammation and hemorrhoid enlargement was observed. The patient underwent a successful manual disimpaction. Guidelines do not require IRB approval Authors examined the literature about occlusion from bezoar The most common causes of occlusion from bezoar are: a previous gastric surgery such as a gastric band (for weight loss) or gastric bypass, a reduced stomach acid (hypochlorhydria) or decreased stomach size, a delayed gastric emptying, typically due to diabetes, autoimmune disorders, or mixed connective tissue disease. Seed bezoars are usually found in the rectum of patients without predisposing factors, causing constipation and pain. Rectal impaction is common after ingestion of seeds while a true occlusion is rare. Although several cases of phytobezoars composed of various types of seeds are reported in literature, bezoars of pumpkin seeds have rarely been reported.

An atypical death from Rapunzel syndrome: a case report

Trichotillomania is a psychiatric disorder characterized by recurring urges to pulling out hairs, eyelashes, or down in other parts of the body. Trichophagia, which is the urge to ingesting the pulled-out hairs, can cause Rapunzel syndrome, an unusual disorder where gastric trichobezoars can be found in the small intestine. Trichobezoars, amorphous masses composed of undigested food formed by hairs, can obstruct the gastrointestinal tract up to simulating symptoms typical of bowel obstruction. Rapunzel syndrome, named after Grimm's tale, may cause death, especially in the pediatric population, being it seldom over the age of 6; moreover, developing countries and environmental and familiar issues are listed as uncertain risk factors. The present case report deals with the death of a 4-year-old female occurred after lunch and following a series of vomit events; while no traumatic or pathological findings were revealed at the external examination, the autopsy revealed three large trichobezoars localized in the stomach and the small intestine. Despite death was due to gastrointestinal obstruction for multiple trichobezoars and collateral bronchoaspiration of dietary material, histological findings were totally non-specific, meaning that it is sometimes difficult to conclude that death is related to the primary pathological condition.

Multiple small bowel perforation in a young adult female due to Rapunzel Syndrome

INTRODUCTION

Rapunzel's syndrome is the state of the gastric trichobezoar (hair ball) extending to the small intestine. Although it is seen very rarely, it is a psychiatric and mental illness especially in young women. We present here, a young female with recurrent trichotillomania.

CASE PRESENTATION

In a 24-year-old patient who underwent laparotomy due to recurrent trichobezoar, which completely filled the stomach and extended to the small intestine, caused perforation in two places in the small intestine, was removed by gastrotomy and enterotomy. One of the perforated areas was very close to ligament of Treitz, and perforation occurred due to the ulcer caused by trichobezoar. Post-operative central total parenteral nutrition was given and oral intake was started at the end of the first week. The patient was referred to psychiatry and antipsychotic medication was started. She was discharged on the 9th postoperative day without any problem.

CONCLUSION

Although there are no signs of peritonitis in such Rapunzel syndrome cases, a detailed exploration should be made by keeping in mind that trichobezoar will cause ulceration and perforation. In addition, as the primary cause is the underlying psychiatric disorder, patients should be referred to the psychiatry clinic to prevent recurrence.

KEY WORDS

Adult, Rapunzel syndrome, Surgery, Trichobezoar, Trichotillomania.

Paediatric gastric trichobezoar: the Rapunzel syndrome A report of two cases

Rapunzel syndrome is a rare case of bowel obstruction resulting from hair ingestion (Trichobezoar). The obstruction can occur in any level of intestinal tract, but usually the stomach is primary involved. This syndrome is usually reported in patients affected by Trichotillomania or Pica syndrome, an obsessive-compulsive disorder that are characterized by an irresistible need to eat body hairs or non-digestible substances 1. When bowel obstruction occurs, it may be treated conservatively, but sometimes surgery is required. We reported two cases of Rapunzel Syndrome in two pediatric patients with different clinical presentation. Both patients were initially treated conservatively but eventually they underwent surgery. KEY WORDS: Bowel obstruction, Rapunzel syndrome, Trichobezoar.

Etiological aspects of intragastric bezoars and its associations to the gastric function implications: A case report and a literature review

RATIONALE

Intragastric bezoar is a stony mass found trapped in the stomach, though it can occur in other locations of the gastro-intestinal tract. The etiology of intragastric bezoar is multifactorial, includes certain risk factors and predisposing factors such as coexisting medical disorders, anatomic abnormalities, and gastric motility disorders, which contribute to the development of intragastric bezoar.

PATIENT CONCERNS

In this report, we present a rare case of intragastric bezoar with epigastric pain after prolonged consumption of jujubes. To our knowledge, this is the first case of intragastric bezoar to be reported after jujubes ingestion.

DIAGNOSES

An upper gastrointestinal (GI) endoscopy performed which revealed an 8 × 5-cm intragastric diospyrobezoar with an adjacent necrotic pressure ulcer of size 0.8 × 0.5-cm without signs of bleeding.

INTERVENTIONS

For therapeutic intervention, Coca-Cola ingestion and lithotripsy were applied.

OUTCOMES

The therapeutic course was uneventful. There was no recurrence during 1-year follow-up.

LESSONS

In our literature, jujube emerged as a new player. A bezoar composed of unripened fruit content in the stomach, could be the cause of chronic abdominal pain, dyspepsia, gastric reflux or heartburn. Moreover, this study provides a detailed overview of recently published literature regarding intragastric manifestations of bezoar, etiological factors, diagnostic and therapeutic approaches.

[A Case of Intestinal Obstruction Caused by a Bezoar after Pylous-Preserving Gastrectomy]

A 65-year-old woman with a history of pylorus-preserving gastrectomy(PPG)for early gastric cancer visited our hospital because of vomiting. Gastrointestinal endoscopy revealed a large bezoar in the anastomotic site of the stomach. Because the bezoar was too large to be collected orally, the dissolution therapy with taking Coca-Cola®was continued. On the 3rd day after hospitalization, she felt acute abdominal pain with vomiting. Computed tomography revealed intestinal obstruction by a mass with air bubbles inside in the ileum. Emergency operation was performed under a diagnosis of intestinal obstruction due to the bezoar. The black brown bezoar sized 80×35×30mm was extracted through an ileotomy. The delayed gastric empty is considered to involve in the bezoar formation. Therefore, the appropriate education of diet and periodic endoscopic screening are necessary for patients with large amounts of gastric residues especially after PPG. In the dissolution therapy, physicians need to be careful of intestinal obstruction by a bezoar.

Renal aspergilloma presenting with pelvi-ureteric junction Obstruction (PUJO)

Primary renal aspergillosis, though a rare entity, is still seen in immune compromised individuals. Renal aspergillosis may lead to formation of focal abscesses, fungal bezoars and may cause ureteric obstruction. Treatment involves stabilization of patient and removal of fungal bezoars along with administration of anti-fungal agents. This report describes the case of localized primary renal aspergillosis with fungal bezoars formation in a 55 years old female, diabetic, hypertensive, who presented with upper urinary tract obstruction and was successfully managed by endoscopic removal of fungal bezoars and intravenous amphotericin followed by oral itraconazole.

Stomach trichobezoar (rapunzel syndrome) with iatrogenic intussusception

We present a rare case of stomach trichobezoar complicated with iatrogenic intussusception noted intra-operatively after failed attempt of endoscopic removal in a 13-year-old girl. At presentation, she had gastric outlet obstruction with anaemia. Endoscopy established the diagnosis of trichobezoar. Surgical removal was warranted after failed endoscopic removal. Her postoperative course was uneventful. Detailed history and careful examination disclosed trichotillomania and associated trichophagia. Psychiatric referral was sought with the intention to prevent future recurrence.

Repeated Small Bowel Obstruction Caused by Chestnut Ingestion without the Formation of Phytobezoars

A small number of cases of small bowel obstruction caused by foods without the formation of phytobezoars have been reported. Repeated small bowel obstruction due to the ingestion of the same food is extremely rare. We present the case of 63-year-old woman who developed small bowel obstruction twice due to the ingestion of chestnuts without the formation of phytobezoars. This is the first reported case of repeated small bowel obstruction caused by chestnut ingestion. Careful interviews are necessary to determine the meal history of elderly patients and psychiatric patients.

''Sandwich'' treatment for diospyrobezoar intestinal obstruction: A case report

Intestinal obstruction is a common clinical entity encountered in surgical practice. The objective of this report is to corroborate an atypical scenario of intestinal obstruction in a Chinese patient and to focus on the diagnosis and treatment. A 27-year-old male presented with a history of gastric pain combined with nausea and abdominal distension that had been present for 5 d. The presence of a foreign body was detected by computed tomography and observed as an abnormal density within the stomach. A diospyrobezoar was revealed during gastroscopy, the extraction of which was prevented due to its size and firmness. An endoscopic holmium laser joined with a snare was used to fragment the obstruction, which was followed by management with a conservative “sandwich” treatment strategy involving intestinal decompression with an ileus tube and Coca-Cola lavage between endoscopic lithotripsy fragmentation procedures. This strategy resulted in the successful removal of the diospyrobezoar along with multiple small bowel obstructions. The patient was discharged after abatement of symptoms. The case presented here demonstrates the implementation of a conservative, yet successful, treatment as an alternative to conventional surgical removal of intestinal obstructions.

A trichobezoar in a child with undiagnosed celiac disease: A case report

Celiac disease is a chronic, immune-mediated enteropathy caused by a permanent sensitivity to ingested gluten cereals that develops in genetically susceptible individuals. The classic presentation of celiac disease includes symptoms of malabsorption but has long been associated with cognitive, emotional, and behavioral disorders. We describe an 8-year-old patient with non-scarring alopecia and diagnosed with trichotillomania. Furthermore, she presented with a 3-year history of poor appetite and two or three annual episodes of mushy, fatty stools. Laboratory investigations showed a normal hemoglobin concentration and a low ferritin level. Serologic studies showed an elevated tissue immunoglobulin G anti-tissue transglutaminase level. A duodenal biopsy showed subtotal villous atrophy and crypt hyperplasia, and a large gastric trichobezoar was found in the stomach. Immediately after beginning a gluten-free diet, complete relief of trichotillomania and trichophagia was achieved. In this report, we describe a behavioral disorder as a primary phenomenon of celiac disease, irrespective of nutritional status.

Clinical characteristics and treatment outcomes of nineteen Japanese patients with gastrointestinal bezoars

OBJECTIVE

To analyze the clinical characteristics of patients with gastrointestinal bezoars and their response to therapy. Patients We retrospectively reviewed the cases of 19 patients diagnosed with gastrointestinal bezoars at the Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences or one of 15 collaborating institutions between December 2004 and August 2013. We investigated the epidemiology and etiology of the gastrointestinal bezoars by determining the gender, age at diagnosis, medical history, symptoms, complications, modalities used for diagnosis, treatments, outcomes and bezoar location, color and contents.

RESULTS

There were 17 patients with gastric bezoars and two patients with small intestinal bezoars. All patients were 62 years of age or older, except for one case of a trichobezoar in a 10-year-old patient. Some of the patients had a history of surgery of any part of the gastrointestinal tract (n=5) and/or diabetes mellitus (n=2). The two patients with small intestinal bezoars required surgical removal in order to relieve ileus. Approximately one-half of the patients with gastric bezoars had ulcerations in the stomach (9/17 patients, 52.9%) and/or gastrointestinal bleeding (8/17, 47.1%). Endoscopic fragmentation was performed in 10 patients, whereas bezoar dissolution was achieved with a gastroprokinetic agent (n=1) and without any treatment (n=3) in the remaining cases.

CONCLUSION

As previously reported, elderly individuals with a positive history of surgery and/or diabetes mellitus were observed in this bezoar patient series. Gastric ulcers and gastrointestinal bleeding were frequently observed. The majority of patients underwent endoscopic fragmentation, while spontaneous resolution of the gastric bezoar was observed in several cases.

[Aggressive endoscopic removal of bezoars effective for the treatment of acute poisoning]

A 37-year-old female presented with acute chlorpromazine and phenobarbital poisoning. Contrast enhanced abdominal CT on admission revealed a high density area at the gastric fundus and residual drugs were suspected. Activated charcoal and cathartics were administered following the gastric lavage under the intubation. As the plasma concentration of phenobarbital was high, urinary alkalinization and crystalloid infusion were carried out to reduce it. However, at 3 days after admission, the plasma concentration level had increased and the consciousness disturbance and respiratory depression continued. Abdominal CT was performed again and bezoars formation was suspected. Endoscopy was carried out to remove the bezoars. After the removal, the plasma concentration level significantly decreased. Her consciousness disturbance and respiratory depression also improved and high density area at the gastric fundus disappeared. Acute endoscopy is seldom advocated in cases of drug overdose. However, aggressive endoscopic removal should be considered in the case of acute poisoning of drugs with form bezoars.

[Gastric bezoar caused by barium sulphate]

We present the first case of a gastric bezoar caused by barium sulphate acting as an intermittently occluding mass in a patient who had undergone small bowel follow-through on suspicion of small bowel obstruction (SBO) after total pancreatectomy. The patient underwent acute surgery but intermittent symptoms of SBO persisted. A barium bezoar was seen on plain abdominal film and afterwards diluted and fragmented gastroscopically. A barium bezoar giving rise to SBO is a possible complication to barium follow-through in patients with impaired gastric transit time.

Respiratory arrest due to airway obstruction following endoscopic removal of Trichobezoar

A trichobezoar is a ball of swallowed hair that collects in the stomach and fails to pass through the intestines. Upper gastrointestinal endoscopy is usually useful for diagnosis and retrieval of a portion of the gastric Trichobezoars but can have complications. Upper airway obstruction may occur during removal of bezoar. This complication may be life threatening. We report the case of a 17-year-old girl who presented with severe anaemia and hypoproteinaemia. During diagnostic upper GI endoscopy, a large piece of hairball compressed the upper airway, leading to cyanosis, respiratory arrest and cardiovascular collapse. The patient was immediately intubated and transferred to the operation room for emergency esophagoscopy. In the operation room, after haemodynamic stabilization the otolaryngologist removed the large piece by esophagoscope. Then the patient was transferred to ICU ward with spontaneous ventilation. The day after, she became stable and conscious.

[Rectal bezoar caused by sunflower seeds]

Phytobezoar is a rare cause of colonic obstruction in Denmark. We describe a case of a 12-year-old boy who was admitted to the hospital because he had not passed stool in two days and complained of anal pain. The boy had consumed about 200 grams of salted sunflower seeds with shells two days before. Treatment with laxanthia and enemas had no effect and he had to be treated with digital evacuation in general anesthesia. Twenty-four hours later, he was discharged from the hospital with normal bowel function.

[Enteric nutrition and esophageal impactation: what relationship]

INTRODUCTION AND OBJECTIVES

In the intensive care unit (ICU), enteral feeding is the method of choice for providing adequate nutrition in intubated patients. The oesophageal impactation (EI) by enteric nutrition (EN) results from solidification of the solution in esophagus lumen with formation of bezoar and although rare, is gradually becoming more common in clinical practice. In recent years some have been diagnosed cases of enteric nutrition impact, in an ICU. The authors seek to better understand their risk factors in order to prevent its occurrence.

METHODS

Retrospective study of patients with endoscopic diagnosis of EI, in ICU, over a period of 3 years.

RESULTS

There were 1367 patients in the ICU, 1003 did EN and 9 had a EI diagnosis. Mean age - 66 years, 7 males, all of them with invasive ventilation support. Mean ICU stay - 32 days, and EI at 20th day, 12 days after started EN. In all the cases, EN is due to the solidification of the EN solution in esophagus. 7 patients had esophageal reflux risk factors: 4 previously known and 3 identified after EI diagnosis. The endoscopic treatment was successful in 7 patients.

CONCLUSION

The EI frequency is low. The ICU average delay (32 days) in this series is twice the total of patients admitted during this period (14,27 days), reflecting the greater severity of the patients studied. Several cases could be implicated in the etiology of that clinical entity. Whenever risk factors are present it should be considered both the endoscopic introduction of nasojejunal tube and specific positioning strategies, to prevent reflux and gastric estasis. Medical and endoscopic treatment solved the majority of related cases that are available in the literature; however, in some specific cases it was necessary to use surgical treatment.

Subacutely formed bezoar resulting from accidentally ingested industrial material

Bezoars are the most common foreign bodies of the gastrointestinal tract. Clinical manifestations vary depending on the location of the bezoar, from no symptoms to acute abdominal syndrome. The ingestion of cling film, which is used for preserving food, may lead to a mechanical obstruction of the gut, especially at the second portion of the duodenal segment, and could manifest with abdominal pain, epigastric distress, nausea, vomiting, and fullness. We report the case of a 72-year-old man who presented with gastric outlet obstruction after accidentally ingesting cling film. He completely recovered after it was endoscopically removed. Cling film is not toxic but has erosive effects. Endoscopic removal of such material is recommended. Moreover, psychiatric intervention and management is imperative to prevent recurrence in such cases.

An unusual case of bleeding from stomach due to a giant diospyrobezoar

Gastric bezoars may be formed in the stomach as a result of foreign body accumulation with inability to pass through the pylorus. Usually bezoars are found in patients with a history of previous gastric surgery. Phytobezoars are the most common type of bezoars. Major complications of bezoars include intestinal obstruction, gastric ulcer, gastric perforation, and bleeding. We present the case of a 51-year-old woman with the features of gastrointestinal bleeding due to a giant diospyrobezoar in the stomach. During endoscopy besides the bezoar, a giant acute ulcer was found. Histological examination of biopsy specimens from ulcer area revealed changes typical of superficial ischemic damage due to prolonged bezoar compression. The patient had undergone a vagotomy and pyloroplasty 13 years ago, and she used to eat two or three persimmons per week during the last six months. The bezoar was fragmented during two endoscopies, and the fragments drifted away through the intestine. We conclude that delayed gastric emptying due to previous gastric surgery and regular eating of persimmons caused the formation of a giant bezoar with ischemic ulcer of gastric mucosa and bleeding. Such pathology potentially could be prevented by dietary advice.

[Peritonitis caused by a giant trichobezoar ventriculi--a case report]

Bezoars are the most common foreign bodies of gastrointestinal tract. They contain swallowed hair, different fibres, seeds, nut shells, sweets or drugs. Clinical manifestations vary, depending on the location and size of bezoar, from "no symptoms" to "acute abdomen" syndrome. In this case report, the authors describe a giant trichobezoar from the stomach of an 18-year-old girl, who had been admitted to the gynecological department with syndromes suggesting an ovarian cyst torsion. The preoperative diagnosis was not confirmed and a giant trichobezoar was found and removed during the surgery.

Management of gastrointestinal bezoars: an analysis of 23 cases

Bezoars (BZs) represent the most common foreign bodies of the gastrointestinal tract. Clinical symptoms varying from no symptoms to acute abdominal obstruction. Our goal is to present our experience with a review of the literature. In this study, 23 patients with BZs of the upper gastrointestinal system (GIS) were treated in the surgical department of two generals hospitals in northwest Greece. The size of BZs, localization, predisposing factors, clinical symptoms, morbidity, and mortality were analyzed. Conservative treatment, endoscopic procedures, and surgical treatment were also parameters under consideration. Nineteen patients presenting with phytobezoars and four female patients presented with psychological disorders and mental retardation with trichobezoars. More than one half of them (57%) had previous gastric surgery. Surgical morbidity rate was 28%, whereas the endoscopic morbidity was 11%. Mortality was 4% and 0% for the surgical and endoscopic groups, respectively. The differences in morbidity and mortality rates between the two groups were not statistically significant. BZs are commonly found in the stomach and small intestine, especially in patients who underwent previous gastric surgery. Small bowel obstruction is the most common complication. When uncomplicated, endoscopic or surgical removal of the BZs can be performed easy and effectively.

Obstructing small bowel bezoars due to an agar diet: diagnosis using double balloon enteroscopy

Primary small bowel bezoars are rare and may cause acute abdomen due to small bowel obstruction (SBO). A 70-year-old Japanese woman presented to the emergency room with abdominal pain, nausea and vomiting. The patient reported that she had eaten a large amount of highly-concentrated, agar dissolved in boiling water two days prior to presentation. Double balloon enteroscopy (DBE) revealed that white-colored, hard bezoars were clogged in the jejunum. At surgery, many bezoars were found impacted in the distal jejunum, and enterotomy was performed. The bezoars were elastic hard, crystallized objects. These bezoars were considered to have formed from highly-concentrated, dissolvable agar.

Duodenal date seed bezoar: a very unusual cause of partial gastric outlet obstruction

Bezoars are concretions of undigested or partially digested foreign material in the gastrointestinal or genitourinary tract of humans or animals. Originally described from Persia, they have been known to mankind for centuries. Bezoars are an uncommon cause of benign mechanical gastric outlet obstruction. A variety of materials have been found to form bezoars, such as hair, undigested food, persimmons, milk products, medicines, etc. Development of bezoars is usually associated with predisposing risk factors. We describe a very unusual case of duodenal date seed bezoar causing partial gastric outlet obstruction in a person with no known risk factors. To the best of our knowledge, duodenal bezoars formed by date seeds have not been reported previously in the English literature.

Gastric bezoar after lung transplantation in non-cystic fibrosis patients and review of the literature

Gastric bezoars have been associated with solid-organ transplantation. In this report we describe the occurrence of gastric bezoars in two patients who underwent sequential single-lung transplantation for severe chronic obstructive pulmonary disease, and analyze the possible pathophysiologic mechanisms responsible.

Gastric bezoar in anorexia nervosa

OBJECTIVE

To report the case of a gastric bezoar in a patient with anorexia nervosa (AN).

METHOD

Case report of a bezoar of the stomach occurring in AN and a review of the literature relating to bezoars and AN from PubMed.

RESULTS

A 19 year-old female presented with a 2-year history of AN binge-purge subtype. After 7 days of complete adherence to diet and no purging in hospital, she complained of increased nausea. She vomited up a cylindrical mass that was sent for pathology. A literature search yielded only one report of a bezoar in AN.

DISCUSSION

Bezoars are agglomerations of food or foreign material in the intestine. They usually present with abdominal pain, intestinal obstruction, weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred method of diagnosis. Clinicians should consider the diagnosis of a bezoar in AN if there is concomitant pica, trichotillomania, or a change in gastrointestinal symptomatology.

Synchronous endoscopic management of bilateral kidney and ureter fungal bezoar

Candidiasis of the lower urinary tract is common in immunocompromised patients. Diabetes and chronic indwelling catheter are two common risk factors for such opportunistic infections. However, upper urinary candidiasis is rare. Further, bilateral synchronous involvement of kidneys and ureter is extremely rare. Treatment usually requires relief of obstruction by percutaneous drainage of the kidney and systemic infusion or local irrigation of antifungal agents. When these measures fail, percutaneous surgical debulking of the fungal bezoar is indicated. We present a case of obstructive anuria due to fungal bezoar in both the pelvicalyceal system and ureter managed by bilateral synchronous endoscopic removal of fungal bezoar.

The tethered bezoar as a delayed complication of laparoscopic Roux-en-Y gastric bypass: a case report

Known complications of Roux-en-Y gastric bypass causing abdominal pain and obstructive symptoms include biliary colic, anastomotic ulcer, anastomotic stenosis, or internal hernia. This case report describes a new complication in a patient 15 months post-bypass: a bezoar at the gastrojejunal anastomosis, the nidus of which was a length of permanent suture material which had eroded through the gastric wall. We include endoscopic images of the bezoar, a review of the related gastric bypass literature, and describe the changes made in our practice as a result of this complication.

Removal of impacted food in children with eosinophilic esophagitis using Saeed banding device

Food impaction in patients with eosinophilic esophagitis is being recognized increasingly. Retrieval of impacted food may be necessary if it does not resolve spontaneously. The present report describes a new technique for removal of friable impacted food from the esophagus using a modified version of the Saeed banding device. With this technique, impacted food was safely removed in a single attempt in each of 3 patients.

A case of pharmacobezoar in a patient with ileostomy

We report a case of a 59-year-old white male who presented with right-sided abdominal pain of 6 months duration. The patient had a total colectomy and Brooks continent ileostomy 20 years ago for severe ulcerative colitis. A CT scan of the abdomen and pelvis revealed large number of pills (pharmacobezoar) in the small bowel, just proximal to the ileostomy pouch. The patient underwent a laparotomy and enterotomy, which resulted in extraction of more than 50 pills from the small bowel. He had no symptoms during the subsequent follow up visits.

Gastric trichobezoar presenting as gastric outlet obstruction--a case report

Trichobezoars are impactions of swallowed hairs in the stomach and occasionally in the intestine. They occur in emotionally disturbed, depressed, or mentally retarded patients who have trichotillomania and trichophagia. Removal of gastric trichobezoar by open surgery (gastrotomy) is a standard approach. Psychiatric follow-up is needed to diminish the recurrence of trichotillomania and trichophagia. Here, we report a case of large gastric trichobezoar presenting as gastric outlet obstruction in a 13-years-old girl. She was treated with open surgical extraction of the bezoar and behavioral therapy.

Laparoscopic management of intestinal obstruction due to phytobezoar

Phytobezoars are a rare cause of small-bowel obstruction and an accurate preoperative diagnosis is very difficult. After diagnosis, the majority of patients in this study underwent surgery. The conventional management of small-bowel obstruction is done by laparotomy. Many studies have demonstrated that laparoscopy can be an alternative to laparotomy for the treatment of small-bowel obstruction in select patients, and it also brings the benefits of minimally invasive surgery. This report demonstrates the case of a patient with intestinal obstruction caused by phytobezoar (mango seed) who was treated laparoscopically. During the laparoscopy, a hard mass 5 cm proximal to the ileocaecal junction was palpable with graspers. An ileotomy was then performed. The bezoar was extracted and inserted into a bag. In this case, the intestinal obstruction management by laparoscopy was safe and feasible.

Bezoar Formation Requiring Endoscopic Removal After Intentional Overdose of Extended-Release Nifedipine

A 61-year-old Caucasian woman was transported to the emergency department after intentionally ingesting several different prescription drugs. She had been found by her husband in an unconscious state with empty bottles of extended-release venlafaxine, extended-release nifedipine, sertraline, and atorvastatin. She was intubated in the emergency department and transferred to the intensive care unit. After 36 hours in the intensive care unit, she was stabilized and brought to a general medical ward. She later developed profound recurrent hypotension with systolic blood pressures ranging from 40-70 mm Hg and diastolic blood pressures of 0-40 mm Hg. She was readmitted to the intensive care unit, where a computed tomography scan revealed a mass in her stomach. A gastroenterology consultation was obtained, and an esophagogastroduodenoscopy (EGD) was performed, during which a large drug bezoar was discovered and removed. The drugs were identified as extended-release nifedipine with a few granules of extended-release venlafaxine. Unfortunately, the patient died 3 days after the EGD from multisystem organ failure related to the overdose. Clinicians who encounter drug overdoses should be aware of the possibility of drug bezoar formation and should consider endoscopic removal as a potential treatment option.

Endoscopic management of a new entity-plastobezoar: A case report and review of literature

Foreign bodies and bezoars are commonly encountered in children. We describe a child aged 11 years who ingested large amounts of plastic material used for knitting chairs and charpoys. The conglomerate of plastic threads, entrapped food material and other debris, formed a huge mass occupying the whole stomach. Chronic irritation of the gastric antral mucosa led to ulceration and formation of hyperplastic polyps. We labeled this new entity as a “plastobezoar”. The entire bezoar could be removed endoscopically.