Gastric Bezoars: A Retrospective Analysis of 44 Cases

Introduction

A bezoar is a mass formed by ingested substances that resist dissolution or digestion within the gastrointestinal tract. While they can occur in any part of the digestive system, bezoars are most commonly found in the stomach [1]. Bezoars are classified into phytobezoars, trichobezoars, lactobezoars, and pharmacobezoars according to their constituent materials, with phytobezoars being the most prevalent [2]. In northern China, gastric bezoars exhibit seasonality and are most common in autumn and winter [3].

Bezoars are an uncommon condition. Although phytobezoars typically develop in the stomach, they can move through the duodenum or the small intestine, leading to mechanical bowel obstruction. To avoid misdiagnosis, other rare conditions, such as Bouveret’s syndrome and gastroduodenal intussusception, need to be differentiated from gastric bezoars [4,5]. Gastric bezoars typically present with non-specific symptoms such as abdominal pain, early satiety, and belching, and they are frequently detected incidentally during upper gastrointestinal endoscopy or imaging [6]. Several risk factors for gastric bezoar formation have been identified, including a history of gastrointestinal surgery, chronic conditions impacting motility like diabetes mellitus, and psychiatric disorders, particularly trichophagia [7–9].

Treatment for bezoars encompasses drug therapy, endoscopic therapy, and surgical interventions. With the ongoing advancements in endoscopic techniques and instruments in recent years, there has been a gradual increase in reports on use of endoscopic lithotripsy, which has emerged as the predominant treatment modality for bezoars [10]. However, the endoscopic treatment of some gastric bezoars can be very time-consuming and labor-intensive, often requiring multiple repeated endoscopic treatments. While there are some studies on bezoars, there are still some issues worth exploring regarding the endoscopic treatment of bezoars.

This study retrospectively analyzed the clinical data and treatment process of 44 patients with gastric bezoars treated at Henan Provincial People’s Hospital from September 2017 to December 2023.

Material and Methods

A total of 44 patients diagnosed with gastric bezoars and treated in the Department of Gastroenterology at Henan Provincial People’s Hospital from January 2017 to December 2023 were included in the study. The study received ethics approval from the Henan Provincial People’s Hospital. Through reviewing our hospital’s medical records and endoscopic operation storage system, the following data were collected: (1) General information of patients, such as sex, age, clinical symptoms, and concomitant comorbidities; (2) Duration, size, and number of gastric bezoars; (3) Endoscopic findings; (4) Number of endoscopic sessions and clinical outcomes. Statistical description and analysis were performed using SPSS 29.0 statistical software. Group comparisons for categorical data were conducted using the chi-square test. A P value <0.05 was considered statistically significant.

Results

PATIENT CHARACTERISTICS:

Among 44 patients, there were 20 males and 24 females, with an age range of 17 to 82 years and a mean age of 55.36±15.17 years. There were 23 patients younger than 60 years and 21 patients aged 60 years or older. After a detailed inquiry into medical history, 19 patients had a history of consuming hawthorn and persimmon, while the dietary history was unknown for 25 patients. Abdominal pain, was the primary symptom associated with gastric bezoars (n=24). Other reported manifestations included nausea and vomiting (n=11), hematemesis (n=3), loss of appetite (n=3), diarrhea (n=1), fatigue and dizziness (n=1), and inability to pass gas and stool (n=1). The time from symptom onset to endoscopic detection of gastric bezoars ranged from 2 hours to 2 years, with a median time of 1 month. Patients had underlying conditions, including diabetes mellitus, hypertension, distal gastrectomy, esophageal cancer surgery, sleeve gastrectomy, liver cirrhosis, and ankylosing spondylitis, as shown in Table 1.

ENDOSCOPIC FINDINGS:

Out of 44 patients, 38 had solitary gastric bezoars and 6 had multiple bezoars. The largest bezoar measured 15×6 cm in diameter, while the smallest was 3×2 cm. Endoscopic examination revealed concurrent ulcers in 36 patients, accounting for 81.8% of all cases of gastric bezoars. The diameter of the ulcer ranged from a maximum of 5 cm to a minimum of 4 mm, 24 cases were smaller than 2 cm, while 12 cases were larger than 2 cm. Among patients with ulcers, 19 were aged <60 years and 17 cases were aged ≥60 years. A comparison between the 2 age groups showed no statistically significant difference (P>0.05). The ulcers showed no relationship with age or the size of gastric bezoars. The most common locations of ulcers were the gastric angle and gastric antrum, with specific distribution detailed in Table 2. Additionally, gastric bezoars-associated ulcers mostly resembled benign ulcers, presenting as relatively regular circular or elliptical shapes. The ulcer base was covered with white exudate or blood scabs, surrounded by congested and edematous mucosa, without nodular changes, and with clear boundaries. A small portion of ulcers appeared as punched-out lesions with raised mucosa at the periphery, making them difficult to differentiate from malignant ulcers. Representative endoscopic images are shown in Figure 1

CLINICAL OUTCOMES:

Our 44 patients all had phytobezoars, with 26 undergoing endoscopic treatment followed by subsequent endoscopic re-examination to ensure complete removal of the bezoars. Nine patients also underwent endoscopic treatment but did not have a re-examination. Four patients were treated solely with oral intake of Coca-Cola, with subsequent endoscopic re-examination revealing removal of the bezoars. The oral intake of Coca-Cola was 3000 ml per day. Three patients received oral Coca-Cola treatment without subsequent endoscopic re-examination. Two patients experienced failure of endoscopic treatment, with 1 requiring surgical intervention and 1 developing septic shock. Among the 26 patients treated with endoscopy, the number of endoscopic treatments ranged from 1 to 4. The average number of interventions per patient was 1.27. Out of the 23 patients who achieved successful treatment after a single endoscopic procedure, the interval for the second endoscopic re-examination ranged from 2 to 6 days, with an average of 3.87±1.22 days. See Tables 3 and 4 for details.

Discussion

Bezoars are a relatively rare condition, particularly in Western countries, possibly due to the lower consumption of persimmons compared to Eastern countries, which leads to a lack of extensive, comprehensive studies on the condition [6,11]. In 1978, Kadian et al reported a bezoar detection rate of 0.43% in 1400 patients [12]. Similarly, in 1987, Ahn et al reported the same incidence of 0.43% over a 7-year period [7]. In 2013, Mihai et al found a detection rate of 0.068% over 20 years [13]. In 2020, Gökbulut et al discovered that the detection rate of bezoars can be as high as 0.9%, while Liu et al found a rate of 0.31% in 23 950 patients [3,14]. Some studies suggested a higher prevalence in females, while others indicated a higher prevalence in males [14–16]. Our study found that bezoars were more frequently observed in female patients. All studies agreed that bezoars tend to occur at a relatively older age. This is consistent with our research, which found the average age of bezoar patients to be 55.36 years. However, a specific type of bezoar, the trichobezoar, is more common among adolescent females. Additionally, we found that abdominal pain was the primary symptom in bezoar patients, consistent with previous studies [15,16]. Diagnosing bezoars based on symptoms alone is difficult, as they are non-specific, making early detection challenging. In our study, the longest duration before diagnosis was up to 2 years. Therefore, in patients presenting with abdominal pain and a history of consuming persimmons or hawthorn, timely endoscopic examination is recommended to avoid missed diagnoses.

Bezoars are believed to form as a result of delayed gastric emptying. Risk factors encompass diabetes mellitus, previous gastric surgery, gastrointestinal tract carcinoma, hypoacidity, and hypothyroidism [8,17]. These conditions lead to reduced gastric acidity, gastric stasis, and loss of pyloric function [18]. Consequently, elderly patients and individuals with diabetes mellitus or a history of gastrointestinal surgery are at a higher risk of developing bezoars due to impaired gastric motility. In our study, the proportion of patients with a history of surgery was 15.9%, and diabetic patients accounted for 11.4%. Additionally, we found that 13.6% of the patients had hypertension. Liu et al suggested that hypertension is a risk factor for gastric bezoars, indicating that hypertension may play a role in their formation [3]. Furthermore, there was 1 patient with liver cirrhosis who had undergone endoscopic sclerotherapy and subsequently developed gastric bezoars. Davion et al considered gastric bezoars to be an adverse effect of endoscopic variceal sclerotherapy [19]. They proposed that endoscopic sclerotherapy might have caused a temporary vagal injury, leading to delayed gastric emptying and the subsequent formation of bezoars. However, a particular type of gastric bezoars, trichobezoars, are most commonly found in children and adolescents. Risk factors include mental retardation and trichotillomania, rather than delayed gastric emptying [20].

Peptic ulcers are frequently detected during endoscopic examinations of patients with gastric bezoars. The current study observed a peptic ulcer incidence rate of 81.8%. In the study conducted by Masaya et al, the incidence of ulcers in bezoars was 64.5% [6]. In the study conducted by Liu et al, the incidence of ulcers was 60.0% [3]. In the study conducted by Iwamuro et al, the rate of ulcers was 52.9% [15]. In the study conducted by Kang et al, the rate of ulcers was 63.6% [21]. The occurrence of ulcers may be related to mechanical friction and compression of the gastric mucosa by gastric bezoars, affecting blood flow. Furthermore, we analyzed the location of ulcers and found that single ulcers were more common. The most common site of ulcers was the gastric angle, followed by the gastric antrum and the gastric body. Ulcers smaller than 2 cm in diameter were more common. There was no apparent relationship between ulcer occurrence and patient age or the size of gastric bezoars. Additionally, despite the high incidence of ulcers in patients with gastric bezoars, the proportion of those with bleeding was not high. In our study, 3 patients experienced hematemesis, consistent with previous studies [15]. Moreover, we found that ulcers in some patients rapidly shrunk after the removal of gastric bezoars.

Treatment options for gastric bezoars include endoscopic therapy involving fragmentation, enzymatic dissolution, and surgical intervention. Several endoscopic techniques and tools have been documented for breaking down bezoars, such as lithotripsy using a basket, polypectomy snare, and biopsy forceps. In our study, all 44 patients had phytobezoars, and the primary treatment methods were endoscopic fragmentation and pharmacological dissolution. Several reports have described the clinical effectiveness of using Coca-Cola to dissolve phytobezoars [22–25]. Ladas et al reported the first successful treatment outcomes with Coca-Cola lavage in 2002, involving 5 patients with gastric phytobezoars [26]. Coca-Cola is chosen for its effectiveness, easy availability, affordability, and safety. Recently, a randomized controlled trial on the treatment of gastric bezoars with Coca-Cola, conducted by Liu et al, revealed a very high success rate in phytobezoar dissolution [27]. However, Delgado et al consider that further research is needed to assess the effectiveness of this approach in patients with a history of gastric surgery, vagotomy, gastroparesis, or other conditions that may affect gastric motility or anatomy [28]. In our hospital, we administered 3000 ml of Coca-Cola orally the day before endoscopic treatment to soften the bezoars and improve the success rate of endoscopic treatment. For a minority of patients who may not be suitable for endoscopic treatment or who prefer Coca-Cola dissolution, we instructed them to orally consume 3000 ml of Coca-Cola daily for 4 days before undergoing endoscopic reevaluation. In our research, gastric bezoars completely disappeared in 30 cases following endoscopic fragmentation and administration of Coca-Cola. Among the 26 patients with gastric bezoars completely removed endoscopically, the average number of endoscopic treatments was 1.27, which is similar to the studies by Park et al and Gökbulut et al, with 1.5 times [14,29]. Of our patient population, 88.5% underwent only 1 endoscopic treatment, while the remaining 11.5% required 2 or more. Park et al indicated that older patients or those with large bezoars were more likely to undergo multiple sessions of endoscopic procedures [29]. A common challenge encountered in the endoscopic treatment of gastric bezoars is the duration between the first endoscopic treatment and the second endoscopic examination. Early endoscopic re-examination may lead to repeated endoscopic treatments due to the incomplete disappearance of gastric bezoars, thereby increasing treatment costs. However, extending the interval for endoscopic re-examination can prolong hospitalization. Previous studies have not reported on this issue. Our center’s experience is an average interval of 3.87 days. The optimal interval may require further confirmation through more research.

Recent studies have shown an improvement in the reported success rate for endoscopic treatment of bezoars, rising from 71.5% to 100% [16,30,31]. In 2 of our patients, endoscopic treatment failed, with 1 developing intestinal obstructions and 1 developing septic shock. Gökbulut et al suggested that the failure of endoscopy was related to the size and type of gastric bezoar [14]. Therefore, while endoscopic removal is relatively successful, surgical intervention remains essential in various scenarios, including cases of intestinal obstruction and endoscopic treatment failure.

Our study has some limitations. It was a retrospective study with a relatively small number of cases, primarily phytobezoars, which have a high success rate with endoscopic treatment. Therefore, the factors contributing to the failure of endoscopic treatment for gastric bezoars could not be further elucidated. Additionally, although our study suggests endoscopic re-examination at around 4 days, more cases are needed to confirm this recommendation.

Conclusions

In summary, gastric bezoars are relatively rare, with phytobezoars being the most common type. With the advancement of endoscopic techniques, the success rate of endoscopic treatment for gastric bezoars is increasing, with most patients requiring only 1 endoscopic treatment for success. Only a small minority of patients require surgical intervention. Furthermore, the appropriate interval for a follow-up endoscopy after the first endoscopic treatment is around 4 days.