Gastric Bezoar

Michael P. Federle, MD, FACR

Key Facts

Terminology

Intragastric mass composed of accumulated ingested (but not digested) material
- Phytobezoar: Undigested vegetable matter
- Trichobezoars: Accumulated, matted mass of hair
- Lactobezoar: Undigested milk concretions
- Pharmacobezoar: Bezoar comprised of medications

Imaging

Mobile intraluminal filling defect
Mottled appearance is result of air bubbles retained in interstices of mass
Small bezoars are rounded or ovoid
- Tend to float on water-air surface surrounded by gastric contents

Pathology

High incidence of peptic ulcers, especially with more abrasive phytobezoars
Predisposing causes
- Previous gastric surgery: Vagotomy, pyloroplasty, antrectomy, partial gastrectomy
- Inadequate chewing, missing teeth, dentures
- Overindulgence of foods with high fiber content
- Altered gastric motility: Diabetes, mixed connective tissue disease, hypothyroidism

Clinical Issues

Bezoars usually form in stomach
- May fragment and enter small bowel where they absorb water, increase in size, and become impacted
- May present with small bowel obstruction
Endoscopic lavage fragmentation and extraction is safe and effective
Drinking several liters of cola beverage has been reported to clear all or portions of phytobezoars

(Left) 60-year-old man with early satiety years after vagotomy and Billroth 1 surgery. Film from an upper GI series shows evidence of the prior surgery and a large heterogeneous “ball” of debris and gas within the stomach mixed with the barium. (Right) Axial CECT shows a laminated mass

in the stomach due to a phytobezoar.

(Left) 3-year-old girl with vomiting. Upper GI series shows a fixed filling defect in the stomach with a swirled pattern of gas and solid material, found to represent a trichobezoar. (Right) Small bowel obstruction following a Billroth 2 procedure. Film from a small bowel follow through shows evidence of the prior gastric surgery and complete obstruction of antegrade flow of barium in the mid-jejunum. At surgery, a phytobezoar was removed, which corresponded to the shape and size of the gastric remnant.

TERMINOLOGY

Definitions

Intragastric mass composed of accumulated ingested (but not digested) material

IMAGING

General Features

Best diagnostic clue
- CT or fluoroscopy: Intraluminal mass containing mottled air pattern
Location
- Sites of impaction: Stomach, jejunum, ileum
  - Narrowest portion of small bowel 50-75 cm from ileocecal valve or valve itself
  - Any part can be affected, especially in patients with postoperative adhesions
Morphology
- Persistent concretions of foreign matter
  - Classified according to material composition
- Phytobezoar: Undigested vegetable matter
  - Poorly digested fibers: Skin and seeds of fruits and vegetables
  - Diospyrobezoar: Persimmons
- Trichobezoars: Accumulated, matted mass of hair
- Trichophytobezoar: Both hair & vegetable matter
- Lactobezoar: Undigested milk concretions
- Pharmacobezoar: Bezoar comprised of medications

Radiographic Findings

Radiography
- Abdominal plain film: Soft tissue mass floating in stomach at air-fluid interface
  - Mottled radiotransparencies in interstices of solid matter
- ± bowel obstruction
- Insensitive test; bezoar identified in 10-18% of patients from radiographs alone

Fluoroscopic Findings

Intraluminal filling defect
- With finely lobulated, villous-like surface
- Freely mobile, without constant site of attachment to bowel wall
Barium or iodinated contrast media outline bezoar
Mottled or streaked appearance; contrast medium entering interstices of bezoar
Filling defect may occasionally appear completely smooth
- Could be mistaken for enormous gas bubble that is freely movable within stomach
Coiled spring appearance (rare)
Partial or complete obstruction
- Try to distinguish obstruction due to postoperative adhesions from bezoar-induced obstruction