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.

The relationship between acid-suppressing drugs and phytobezoar formation: a retrospective analysis and discussion of phytobezoar formation.

OBJECTIVES: Although phytobezoars are a rare cause of gastrointestinal obstruction, they are most commonly found in patients with previous gastric surgery. It is well known that predisposing factors of phytobezoar formation are ingestion of fruits containing soluble tannin, presence of dilute hydrochloric acid in the stomach, and gastric stasis or delayed emptying. We investigated whether intake of acid-suppressing drugs that neutralize gastric acidity or inhibit gastric acid secretion to constitute a hypo-acidic condition, increases the risk of phytobezoar formation. MATERIALS AND METHODS: Between September 1992 and October 2008, 32 patients (24 male and 8 female) with gastrointestinal phytobezoars were diagnosed either surgically or endoscopically at the Tri-Service General Hospital, Taipei, Republic of China. The data were collected from hospital records and analyzed retrospectively. RESULTS: Eighteen (56.25%) of all patients had previous gastric surgery and 6 (42.9%) of the 14 patients who had not undergone surgery had diabetes mellitus. The majority of admissions were during winter and spring (between October and March) (P < 0.01) and none of the patients had taken acid-suppressing drugs during the 6 months before detection of gastrointestinal phytobezoars. CONCLUSIONS: In our study, intake of acid-suppressing drugs did not increase the risk of phytobezoar formation in patients with normal gastric motility. Moreover, we believe that the major factor in phytobezoar formation is gastric stasis or delayed emptying, which sufficiently prolongs the retention period of materials in the stomach, while dilute hydrochloric acid is a minor factor.

Pyloric sphincter dysfunction in nNOS-/- and W/Wv mutant mice: animal models of gastroparesis and duodenogastric reflux.

BACKGROUND & AIMS: Nitrergic nerves and interstitial cells of Cajal (ICC) have been implicated in the regulation of pyloric motility. The purpose of these studies was to define their roles in pyloric function in vivo. METHODS: Pyloric sphincter manometry was performed in wild-type controls, neuronal nitric oxide synthase-deficient (nNOS(-/-)) mice, and ICC-deficient W/W(v) mice, and the effect of deafferented cervical vagal stimulation was examined. RESULTS: Mice showed a distinct approximately 0.6-mm-wide zone of high pressure at the antroduodenal junction, representing the pyloric sphincter. In wild-type controls, the pylorus exhibited tonic active pressure of 12.4 +/- 1.6 mm Hg with superimposed phasic contractions. The motility indices, minute motility index, and total myogenic activity were reduced by vagal stimulation, and the reduction was antagonized by the nitric oxide synthase inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME). In nNOS(-/-) mice, pyloric basal tone, minute motility index, and total myogenic activity were not significantly different from those in controls, but vagal stimulation paradoxically increased pyloric motility. In contrast, the W/W(v) mice had significantly reduced resting pyloric pressure that was suppressed by vagal stimulation in an L-NAME-sensitive manner. The stomachs of fasted nNOS(-/-) mice showed solid food residue and bezoar formation, while W/W(v) mice showed bile reflux. CONCLUSIONS: In nNOS(-/-) mice, loss of nitrergic pyloric inhibition leads to gastric stasis and bezoars. In contrast, basal pyloric hypotension with normal nitrergic inhibition predisposes W/W(v) mice to duodenogastric bile reflux.

Observation on the curative effect of long intestinal tube in the treatment of phytobezoar intestinal obstruction.

The aim of the study was to observe the curative effect of long intestinal tube (LT) in the treatment of phytobezoar intestinal obstruction.We performed a retrospective study of patients with phytobezoar intestinal obstruction who underwent decompression with different tube insertion method. A total of 80 patients were collected and divided into nasogastric tube (NGT) group (n = 36) and LT group (n = 44) between August 2015 and August 2018 at our hospital. Univariate analysis was used to assess the clinical efficacy of 2 groups of patients.There were no significant differences in the mean age, sex ratio, and previous surgical history between the 2 groups. There were statistically significant differences between the 2 groups in terms of improvement time of clinical indications (4.2 ±â€Š1.4 vs 2.5 ±â€Š0.6 days; P = .008), liquid decompression amount on the first day of catheterization (870.4 ±â€Š400.8 vs 1738.4 ±â€Š460.2 mL; P = .000), transit operation rate (4/36 vs 0/44; P = .023), clinical cure rate (25/36 vs 40/44; P = .014), total treatment efficiency (32/36 vs 44/44; P = .023), and total hospitalization cost (3.25 ±â€Š0.39 vs 2.07 ±â€Š0.41 ¥ ten thousand; P = .000).The curative effect of LT in the treatment of phytobezoar intestinal obstruction is accurate and reliable, which can effectively improve the clinical symptoms of patients, comprehensively improve the non-surgical rate of intestinal obstruction treatment, reduce the total cost of hospitalization, and is worthy of promotion in clinical application.

Rapunzel syndrome in adult with mysterious presentation: a rare case report with literature review.

Bezoars are indigestible foreign material in the gastrointestinal tract (GIT). A phytobezoar is a mass of plant material, while a trichobezoar consists of matted hair. This is found most commonly in the stomach in children who chew their long hair. When a gastric trichobezoar extends to the duodenum or jejunum, this is known as Rapunzel syndrome (RS), after a famous Brothers' Grimm fairy tale. Our patient presented with haematemesis, localised peritonitis, a palpable epigastric mass, coagulopathy, severe anaemia and deranged liver function tests. An abdominal computed tomography scan was suggestive of a bezoar; gastroduodenoscopy confirmed the diagnosis. Treatment of trichobezoars normally involve endoscopic removal or gastrotomy and psychiatric intervention. They may also cause haematemesis, gastric outlet obstruction, gastric ulceration and perforation, multiple jejuno-jejunal intussusception, acute pancreatitis and cholestatic jaundice. Trichobezoar was first reported in the 18th century by Baudamant in a 16-year-old boy. RS was first described in 1968.

Prediction of Small Bowel Obstruction Caused by Bezoars Using Risk Factor Categories on Multidetector Computed Tomographic Findings.

Objectives. The aim of this study was to detect factors associated with small bowel obstruction (SBO) caused by bezoars on multidetector computed tomographic findings. Methods. We retrospectively reviewed 61 patients who had bezoars in the small bowels on MDCT. The patients were divided into SBO patients group and non-SBO patients group. The mean values of the diameter, volume, and CT attenuation as well as location and characteristics of the bezoars were compared between the two groups. Multivariate analysis was performed to determine factors associated with SBO. Results. There were 32 patients (52.5%) in the SBO group and 29 patients (47.5%) in the non-SBO group. The bezoars in the SBO group had greater values of each mean diameter and mean volume than those in the non-SBO group (3.2 ± 0.5 cm versus 1.6 ± 0.7 cm, P < 0.0001, 14.9 ± 6.4 cm(3) versus 2.5 ± 2.7 cm(3), P < 0.0001, resp.) and had a lower CT attenuation than the non-SBO group (55.5 ± 23.4 versus 173.0 ± 68.0, P < 0.0001). The SBO group had higher prevalence of phytobezoar appearance (75.0% versus 10.3%, P < 0.0001). Major diameters of bezoar and phytobezoar were significant independent risk factors associated with SBO (odds ratio = 36.09, 8.26, resp., and P = 0.0004, 0.044, resp.). Conclusions. Major diameter of bezoar or phytobezoar is a potential risk factor associated with SBO.

Gastric emptying and bezoars.

Bezoars are conglomerates of undigested material in the stomach, which appear as a late complication of gastric surgery and are presumably related to secondary motility changes. We studied the gastric emptying of a technetium-99m-(Tc 99m) labelled solid meal in 10 patients who presented with a bezoar 1 to 20 years after vagotomy and pyloroplasty, vagotomy and antrectomy, vagotomy and gastrojejunostomy, or hemigastrectomy. The results were compared with the emptying data of operated patients without bezoars. The gastric retention of Tc 99m-labelled solids at 45, 75, and 105 minutes was 85 +/- 15 percent (mean +/- SD), 79 +/- 17 percent, and 65 +/- 24 percent, respectively. No differences were found when results were compared with those of operated patients without bezoars. We concluded that factors other than the gastric digestive phase are the main contributors to bezoar formation.

Bezoars and foreign bodies of the stomach.

Bezoars are usually encountered in patients with altered gastric anatomy or function. Symptomatic, large phytobezoars or trichobezoars may require endoscopic fragmentation or surgical removal. Foreign bodies of the stomach are usually a self-limited problem, because at least 90% pass without symptoms, in patients with normal gastrointestinal anatomy. Endoscopic removal should be considered for sharp, pointed, or long objects, or in patients with altered anatomy, such as intestinal stricture.

Foreign bodies, exogenous & endogenous triggering mechanical effects, good/bad, in the airways. The anesthesiologist as the diagnostician.

Fifty odd years ago, in his historic book, 'The Silent World,' Jacques Cousteau told us that scuba divers breathing compressed air were apt to get a 'high,' which he called, 'Rapture of the Deep,' and a form of cerebral arrest, which he termed, 'Nitrogen Narcosis'. Furthermore, these submarine soloists, also like persons under general anesthesia, are prone to mysterious sudden death. All this reminds us of 'ether parties,' and contemporary snorters and huffers, sniffing such foreign bodies as, glue, cocaine, paint-thinner, gasoline, spray-can-propellant, etc. Relevant is the fact that the endogenous and other soporifics which arise within the body proper (endo-integumentarily) do not induce general anesthesia, which is cerebral arrest, until they have entered the extra-integumentary mucosal compartments called airways. Nitrogen is an inert gas, so its actions are neither toxic nor chemical, but mechanical. The effects of endogenous soporifics such as acetone, carbon dioxide, alcohol, and ammonia, are usually assumed to be toxic and endo-integumentary. Therefore, I must emphasize the fact that they do not cause 'Highs,' somnolence, nor deaths until/unless they have entered the extra-integumentary airways. Certainly those agents may also have some endo-integumentary actions. I must also stress the fact that foreign bodies in the airways which do not pierce the integument to enter the body proper, such as endotracheal or tracheostomy tubes, lumps of meat, mucus plugs (boogers), etc., can also occasionally trigger cerebral, respiratory and even cardiac arrests locally and mechanically in the airways, depending on which trigger points they stimulate and how powerfully. Four points explain the mechanism of general anesthesia: (a) Endogenous soporifics do not induce sleep until they have entered the extra-integumentary airways, and contacted the mural mucosa; (b) however administered, intravenously, rectally, or by inhalation, exogenous general agents do not anesthetize until they enter the airways and contact the extra-integumentary mucosa; (c) other foreign bodies, e.g., mishandled endotubes in the airways, which cannot pierce the integument to enter the body proper, can and do trigger cerebral/respiratory/cardiac arrest locally, mechanically, and extra-integumentarily. These effects are neither toxic, nor chemical; (d) Some agents, which can and do pierce the integument, having induced anesthesia, will later exit the body chemically unchanged by their endo-integumentary sojourn, which suggests that their modus operandi is mechanical.

Bezoars, stones, thrombi, thrombophlebitis, emboli, vascular disorders, paralytic ileus, intercellular extravascular glue and dessication: fundamental physical factors in the formation of concretions.

Usually blood does not stagnate nor clot in its vessels. Spasm in a vein or artery, constricting the wall or sphincter, seines and assembles the ingredients of a thrombus. It further leads to rupture of the vessel's wall, so extravascular glue can complete or augment the recipe. The mechanisms of blood clotting, include three prime factors, stasis, dessication and extravascular glue. Idiopathic disorders of the arteries and veins and similar to each other and to those in other systems and, e.g. analogous to paralytic ileus and intestinal obstruction. Dissecting, i.e. intralaminar hemorrhage in the pathogenesis of emboli, venous/arterial and vascular occlusion, merits more attention as do the sphincters and valves of the vascular system.

Gastric phytobezoar associated with impaired gastric motility in a patient with spinal cord injury.

Impaired gastrointestinal motility as a result of interruption of sympathetic outflow is a common occurrence in the spinal cord injury (SCI) population. In addition, frequent use of medications with anticholinergic properties in this population results in further impairment of peristalsis resulting in gastrointestinal stasis. Since SCI patients often lack sensation below the level of injury, they may present with vague symptoms, which complicates the diagnosis of intestinal obstruction. We report the first case of gastric phytobezoar in a patient with T4 ASIA A paraplegia who presented with vague upper abdominal discomfort, anorexia, weight loss, and vomiting. Because mortality rates can be as high as 30% if phytobezoars remain untreated, gastrointestinal phytobezoars should be considered in the differential diagnosis of abdominal discomfort in SCI patients. Etiologic factors for phytobezoars are discussed for the general population and in particular, for patients with SCI.

Rapunzel syndrome with a long tail.

A rare form of gastric trichobezoar extending into small bowel with varying gastrointestinal symptoms is known as Rapunzel syndrome. A case history of 6 years old boy is described. This is the twelfth patient with Rapunzel syndrome in the literature.

[Trichobezoars].

Trichobezoars are accumulations of hair casts in the stomach associated with trichophagia. The typical patient is an adolescent female who presents with alopecia and an upper abdominal mass which on moving can cause intermittent gastric outlet obstruction. Only a minority of patients have severe psychiatric disorders. When hair strands extend from the main mass in the stomach, all along the small bowel and reaching the cecum, the condition is termed the Rapunzel syndrome. In about 5% of patients there are separate hair masses in the stomach. The clinical presentation includes abdominal pain, loss of appetite, weight-loss, vomiting, loose stools, pancreatitis, jaundice, anemia and hypoalbuminemia. These signs and symptoms raise the suspicion of malignancy. Complications of bezoars include ulcers, perforation of the bowel, obstruction and intussusception. Diagnosis can be established either by barium swallow or by CT scan. Ultrasound might suggest the diagnosis, but sonographic features are definitely not pathognomonic. Treatment is surgical, as endoscopic removal is usually unsuccessful. We present 2 children in whom trichobezoars were found.

[Rapunzel syndrome: a report of a new case]. / Síndrome de Rapunzel. Aportación de un nuevo caso.

The Rapunzel Syndrome is a rare form of gastric trichobezoar extending throughout the bowel. A 8-year-old girl was admitted to our institution with a six months history of vomiting and astenia. Upper gastrointestinal contrast study showed a lot of filling defects in stomach and the first bowel loops. At laparotomy a large intraluminal mass is observed. Gastrotomy revealed a large tricobezoar with intestinal extension to jejunum, that were extracted. In rare instances, this syndrome presents with a confusing clinical picture. A detailed medical history is an essential point in the diagnosis.

[Mechanical intestinal occlusion due to phytobezoars]. / L'occlusione meccanica intestinale da fitobezoario.

The Authors reporting two cases with ileus by phytobezoar in distal jejunum and ileum, respectively, and discuss the pathophysiologic mechanism responsible for the formation of bezoars. They expose the etiological and clinical factors of this uncommon cause of small bowel obstruction and also discuss the surgical technique that consists in the removal of the phytobezoar through enterotomy.