Bezoars

What a bezoar is

The stomach normally grinds food and empties it into the small intestine. Material that cannot be digested, such as plant fiber or hair, usually passes through. If it is eaten in large amounts, or the stomach empties too slowly, the material can gather and compress into a solid mass. Over time, more material is trapped, and the bezoar grows.

Types of bezoar

A trichobezoar that extends from the stomach into the small intestine is called Rapunzel syndrome.

Causes and risk factors

• Slow stomach emptying: gastroparesis, commonly from diabetes, is the leading risk factor.
• Stomach surgery: partial gastrectomy, vagotomy and some weight-loss operations reduce stomach grinding and acid.
• Poor chewing: missing teeth or poorly fitting dentures.
• High-fiber diets with large quantities of fibrous fruits and vegetables in susceptible people.
• Hair-pulling and hair-eating: trichotillomania with trichophagia.
• Medicines that slow the gut, such as opioids and anticholinergics.
• Pica and developmental conditions that lead to swallowing non-food items.

Symptoms

Small bezoars may cause no symptoms. Larger ones can cause:

• fullness after small amounts of food (early satiety)
• nausea and vomiting
• upper belly pain or discomfort
• loss of appetite and weight loss
• bad breath, especially with hair bezoars
• a lump that can be felt in the upper abdomen

Complications

• gastric ulcers and bleeding from pressure on the stomach lining (see peptic ulcer)
• gastric outlet obstruction or small bowel obstruction if a fragment moves on
• perforation of the stomach or bowel, which is rare but serious
• malnutrition and anemia, especially with large trichobezoars

Diagnosis

• Upper endoscopy: a camera passed through the mouth shows the bezoar directly and identifies its type. It is the preferred test and often allows treatment at the same time.
• CT scan: shows the size and location, especially in the small intestine, and detects obstruction.
• X-ray or barium study may show a mass.
• Blood tests: for anemia and nutritional deficits.

Treatment

Dissolution

• Coca-Cola lavage: drinking or infusing cola dissolves many phytobezoars, likely because of its acidity and carbon dioxide. It is often tried first, sometimes combined with endoscopy.
• Enzymes such as cellulase and papain are used less often.

Endoscopic removal

Doctors break up the bezoar with tools such as snares, forceps, jets of water or lithotripsy devices and remove the pieces or let them pass.

Surgery

Needed for large trichobezoars (which rarely dissolve), Rapunzel syndrome, bowel obstruction, perforation, or when other methods fail. Laparoscopic surgery is often possible.

Prevent recurrence

• treat gastroparesis with diet changes and medicines that help the stomach empty
• chew food thoroughly and fix dental problems
• avoid or limit high-risk foods such as persimmons if you have gastroparesis or past stomach surgery
• treatment for trichotillomania, such as habit reversal therapy
• review medicines that slow the gut

Frequently asked questions

What is a bezoar?

A bezoar is a solid mass of undigested material, such as plant fiber, hair or medicine, that collects in the stomach or intestine. It is most common in people whose stomach empties slowly or who have had stomach surgery.

What foods cause bezoars?

High-fiber foods that are hard to digest are the most common culprits, especially persimmons, along with celery, pumpkin, prunes, raisins, leeks, pineapple and citrus pith. They mainly cause problems in people with gastroparesis or previous stomach surgery.

How are bezoars removed?

Many phytobezoars can be dissolved with cola, sometimes with enzymes, or broken up and removed during endoscopy. Large hair bezoars and bezoars that cause a blockage or perforation usually need surgery.

Can a bezoar pass on its own?

Small, soft bezoars sometimes break up and pass, especially after dissolution treatment. Larger or harder ones, including most hair bezoars and persimmon bezoars, usually need endoscopic or surgical removal.