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 bazahr, "bezoar" or ultimately from Middle Persian p'tzhl padzahr, "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.

Endoscopic Treatment of Postoperative Bleeding, Bezoars, and Foreign Bodies.

Altered gastrointestinal anatomy is common in patients with inflammatory bowel disease, particularly in those who underwent bowel surgery. Commonly performed surgeries are bowel resection and anastomosis and strictureplasty for Crohn's disease; and restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. The area of anastomosis and suture line is at the greatest risk for the development of postoperative bleeding. Altered bowel anatomy, especially the presence of strictures, strictureplasty, or structural or functional pouch outlet obstruction, puts these patients at risk for bezoar formation and foreign body retention, including video endoscopy capsule. This article will focus on postoperative bleeding, bezoar formation, and video capsule retention in patients with inflammatory bowel disease. Endoscopic management of these conditions is useful and is becoming an increasingly popular alternative to surgery.

Esophageal pharmacobezoar: a very unusual complication of enteral nutrition use.

Enteral nutrition in intensive care has been a great advance in medicine, due to its benefit, cost-effectiveness and few complications. Bronchoaspiration, diarrhea, regurgitation or mechanical problems are the main adverse effects. Esophageal obstruction by bezoar is a very infrequent complication, and there are only a few cases described in the literature.

Sex Differences in Age at Onset and Presentation of Trichotillomania and Trichobezoar: A 120-Year Systematic Review of Cases.

Trichotillomania (hair-pulling disorder) has high female preponderance. It has been suggested that onset in early childhood represents a distinct developmental subtype that is characterized by higher prevalence of males compared to later onset cases. However, the empirical literature is scarce. We conducted a systematic review of case reports to examine the distribution of age at onset/presentation in males and females with trichotillomania or trichobezoar (a mass of hair in the gastrointestinal tract resulting from ingesting hair). We identified 1065 individuals with trichotillomania and 1248 with trichobezoar. In both samples, males, compared to females, had earlier age at presentation and greater proportion of cases in early childhood. These sex differences remained after potential confounding variables were accounted for. The results showed similar sex differences for age at onset, which was reported in 734 and 337 of the trichotillomania and trichobezoar cases, respectively. The findings may reflect neurodevelopmental underpinnings in early childhood trichotillomania.

[Gastric bezoars caused by enteral nutrient gel via gastric fistula in a patient with esophageal cancer].

A 62-year-old man presented to our hospital with difficulty in swallowing. Physical examination and subsequent diagnostic tests identified hypopharyngeal and esophageal carcinoma with tracheal invasion. The patient underwent gastric fistula placement, radiotherapy, and chemotherapy. Palliative care was initiated after recurrence. The patient was later hospitalized for neck pain, and during a routine exchange of the gastric fistula, two large bezoars were found. The enteral nutrient gel was discontinued, cola was administered, and the bezoars gradually reduced. He continued to receive home care, and later when he was hospitalized for mediastinal abscess, no bezoars were identified. This case highlights the possibility of bezoar formation as a rare complication of enteral nutrition gel administration.

A Simple Method for Endoscopic Treatment of Large Gastric Phytobezoars: "Hand-Made Bezoaratome".

BACKGROUND: Large gastric phytobezoars are generally resistant to standard chemical or endoscopic treatments. We presented our experience of an alternative endoscopic method using a hand-made tool called a "hand-made bezoaratome" for the treatment of large gastric phytobezoars. METHODS: Patients who consulted or who were diagnosed with gastric bezoars at an education and research hospital between January 2015 and December 2018 were prospectively included in the study. Patients with phytobezoars of 50 mm and larger were included in the study. Patients with trichobezoars, lactobezoars, pharmacobezoars, under 18 years of age, and pregnant women were excluded. A 0.25 mm diameter guidewire and a mechanical lithotripter sheath were used to prepare the "hand-made bezoaratome." After the first procedure, patients were advised to consume 2500 mL of Coca Cola® or the same amount of pineapple juice per day, until the next procedure. Endoscopic procedures were performed at 5-day intervals until complete reabsorption of the bezoar was achieved. Patients were followed up for 6 weeks. RESULTS: The study group included 37 (21 males, mean age: 57.6 ± 12.5 years) patients. The median size of the phytobezoars was 71 mm (50-90). The median endoscopic procedure time was 853 s (380-1940 s). The success rate for endoscopic fragmentation was found to be 100%. No major complications occurred during the endoscopic procedures, but 1 patient (2.7%) required surgery for ileus due to an obstruction at the distal part of the jejunum, 61 h after the second endoscopic session. The overall success rate of the endoscopic treatment was 97.3%. CONCLUSION: Using a "hand-made bezoaratome" is effective and reliable for the endoscopic treatment of large gastric bezoars.

Does Feeding Previously Frozen (Thawed) Fortified Human Milk Increase the Incidence of Lactobezoar (Milk Curd) Obstruction? A Retrospective Cohort Study in One Large Neonatal Intensive Care Unit.

BACKGROUND: Current recommendations suggest that it is appropriate to store human milk (HM) for up to 24 hours following fortification despite any changes that may occur in fortified HM over time. However, a recent publication suggested fortified frozen HM should be thawed and fed within 12 hours of fortification due to the risk of lactobezoar or milk curd obstruction. OBJECTIVE: This study investigated whether lactobezoar (milk curd) formation increased when frozen fortified HM was thawed and fed within 12 hours vs 12 to 24 hours postfortification in the neonatal intensive care unit (NICU) at Children's Hospital of Orange County to determine if practice changes were warranted. DESIGN: This study was a retrospective cohort study. PARTICIPANTS/SETTING: All infants admitted to the Children's Hospital of Orange County NICU for calendar years 2018-2019 who were fed fortified human milk (n = 802) were included in the study. EXPOSURE VARIABLE: Feedings using previously frozen (thawed) fortified HM. MAIN OUTCOME MEASURE: Lactobezoar or milk curd formation. STATISTICAL ANALYSIS: Descriptive analyses were used for statistical analysis. RESULTS: Of the 107,602 feedings prepared with fortified thawed HM, 68% (72,602) were used within 12 hours of preparation and 32% (34,499) were stored for 12 to 24 hours before administration. The NICU at Children's Hospital of Orange County did not identify any lactobezoar formation or milk curd obstruction in either group. CONCLUSIONS: Data from this study support recommendations for a maximum storage time for thawed, fortified HM of 24 hours.

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.

Phytobezoar-induced small bowel obstruction in an elderly patient undergoing dialysis: a case report.

A phytobezoar is defined as an accumulation of poorly digested fruit and vegetable fibers in the gastrointestinal tract. Phytobezoar-induced small bowel obstruction is an uncommon entity and is usually removed surgically. We herein describe an elderly man undergoing dialysis who developed a phytobezoar because of excessive consumption of high-fiber fruits and inappropriate chewing. His potential predisposing factors were dialysis-related lifestyle changes, reduced activity levels, fluid restriction, and gastrointestinal motility dysfunction; however, he had no history of gastric surgery. The patient's clinical history and characteristic imaging features aided in the diagnosis. He underwent medical treatment, and his recovery was uneventful. This case highlights the importance of an awareness of phytobezoar-induced small bowel obstruction in patients at increased risk of developing bezoars and demonstrates that this condition can occur in the absence of previous gastric surgery. We believe that elderly patients undergoing dialysis are at increased risk of developing bezoars. Excessive consumption of a strictly fibrous diet and insufficient chewing exacerbate the risk. A detailed dietary history and imaging features can aid in early diagnosis, leading to appropriate medical or surgical care. Surgical treatment is not inevitable in all cases. Individualized dietary suggestions in these patients are important for effective preventive control.

A Bariatric Curveball: A Rare Case of Recurrent Lactobezoars after Roux-en-Y Gastric Bypass Surgery.

Bariatric surgery is a major risk factor for bezoar formation secondary to decreased gastric motility, gastric acidity, and pyloric function.1 This case is about a 49-year-old female veteran, 3 weeks status-post Roux-en-Y gastric bypass surgery, who presented with acute abdominal pain and oral intolerance. After being diagnosed with a bezoar and esophagogastroduodenoscopic removal, the patient had immediate relief of symptoms. Unfortunately, over the course of 4 months, this patient experienced three recurrent episodes of bezoar formation (with a possible fourth episode that could not be confirmed secondary to resolution of symptoms after administration of oral contrast load). Based on her dietary history and gross appearance of the bezoar, the patient was determined to have developed recurrent lactobezoars. Lactobezoars are composed of milk and mucous proteins and are commonly found in neonates with immature gastrointestinal tracts.7 This unusual complication demonstrates how current dietary recommendations encouraging dairy consumption to meet daily protein requirements may have increased this patient's risk for lactobezoar formation. This case illustrates the importance of balancing the risks and benefits of macronutrient requirements after bariatric surgery with postsurgical bezoar complications.

Human and Doll's Hair in a Gastric Trichobezoar, Endoscopic Retrieval Hazards.

Trichobezoars are masses of ingested hair, usually the individual's own hair, that accumulate in the gastrointestinal tract, most commonly in the stomach. When extending into the small intestine, this is termed "Rapunzel syndrome." Removal has traditionally been by laparotomy; however, successful endoscopic removal has also been described. We report the case of a 9-year-old-girl with undiagnosed coeliac disease and Rapunzel syndrome who underwent endoscopic removal of a large trichobezoar, which was followed by unexpected multiple perforations of the small bowel and stomach. Argon plasma coagulation (APC) and snare electrocautery were employed during endoscopy to remove the trichobezoar piecemeal, and approximately 70% was removed without any clear signs of damage to the mucosa. It was discovered subsequently that about 20 of her dolls were found without hair. On investigating the composition of a specific doll hair from the manufacturer, it was discovered that it could be hazardous if burned. It was, therefore, hypothesized that a constellation of factors had conspired to lead to perforation, that is, the potentially hazardous gas produced from the electrical energy applied to the synthetic hair and possible mucosal damage by the physical abrasion of this hair. A review of the literature on endoscopic attempts to remove trichobezoars irrespective of the result reveals a success rate of 30.7%.

Case Report: Phytobezoar Causing Gastric Outlet Obstruction as a Late Complication After Biliopancreatic Diversion with Duodenal Switch.

Case report of a phytobezoar causing gastric outlet obstruction as a late complication after biliopancreatic diversion with duodenal switch, review of the literature and discussion of bezoars as a differential diagnosis in patients after bariatric surgery presenting with signs of intestinal obstruction.