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phytobezoar

Phytobezoar

Phytobezoar is a bezoar (indigestible masses) composed of fruit and vegetable fibers and phytobezoar is a relatively common cause of small bowel obstruction in the absence of previous gastric surgery 1. Phytobezoars, the most common type of bezoars, are composed of indigestible cellulose, tannin, and lignin derived from ingested vegetables and fruits 2. Food types that lead to phytobezoar formation include persimmons, oranges, coconuts, apples, green beans, sauerkraut, figs, berries, Brussels sprouts, and potato peels 3. Phytobezoar as a cause of small bowel obstruction has risk factors such as intake of large amount of food with high-fiber content and inadequate chewing 4. The dietary habit of having large amount of vegetables and fruit in Asian countries can be result in phytobezoar formation 5. In some Asian countries, phytobezoars are formed after ingestion of persimmons and pineapples and are called diospyrobezoars, which are more difficult to treat because of their hard consistency 6. Large phytobezoars are generally retained in the stomach. However, they may occur in the duodenum in patients who have undergone gastric surgery.

Although the reported incidence is less than 0.4 % in the general population, phytobezoar may be associated with a high mortality 7. Therefore, it is very important to remove the bezoar in order to prevent further complications.

Bezoars are masses produced by accumulation of undigested material such as fruit, hair, and milk in gastrointestinal tract more frequently in stomach 5 and one of the most common types of bezoar is phytobezoar 8, composed of fruit and vegetable fibers. Excessive consumption of foods with high fiber content is a dietary factor. Inadequate chewing can result of dental problems such as difficult chewing following loss of teeth that frequently seen in older age group 9. Moreover, inadequate chewing in part is related to habits. Other factor in aging population is loss of intestinal elasticity, as a physiologic change commonly seen in this group, and resultant constipation 9 may be considered as another reason for increased chance of intestinal phytobezoar formation. In other words, intestinal phytobezoar formation is a multifactorial entity, involving dietary and alimentary factors 10 and dental hygiene. Therefore, good dietary habit and proper dental hygiene in lifetime are necessary for maintaining a healthy population especially in older adults.

Phytobezoar symptoms

Clinical manifestations of phytobezoar vary from no symptoms to acute abdominal distress including epigastric discomfort, abdominal pain, vomiting or nausea, and in severe cases, gastric ulceration, upper gastrointestinal bleeding, and perforation 11.

Phytobezoar diagnosis

CT scanning and endoscopic investigations can show and confirm almost all duodenal phytobezoars 12.

Phytobezoar treatment

Phytobezoars can be treated in several ways including pharmacologic dissolution, endoscopic procedure, and surgical treatment; however, there is no consensus regarding the management. Phytobezoars’ conservative management includes administration of proteolytic enzymes, cellulase, carbohydrate beverages, either orally or by gastric lavage, and endoscopic fragmentation 13. Small bowel obstruction due to phytobezoar may need surgery for treatment and this entity rarely improves with conservative therapy, hence it is important to consider this diagnosis as the reason for small bowel obstruction 4. In patients with small bowel obstruction that have history of recent consumption of vegetables or food with high fiber content and no past history of surgery, phytobezoar should be kept in mind with high index of suspicion 14.

Persimmon phytobezoar, because of its particular features, should be considered separately from other phytobezoars, especially as far as treatment is concerned 15. The almost stony consistency of these phytobezoars renders the nonoperative treatments used for other phytobezoars ineffective 15. Because of persimmon phytobezoars’ hard consistency, a single endoscopic fragmentation or dissolution therapy is difficult and sometimes cannot be successful used. In a case study, doctors initially tried to endoscopically remove the phytobezoar but this was not possible because the phytobezoar was very hard and removal could cause bowel perforation. Two liters of Coca-Cola a day combined with endoscopic fragmentation for 4 days was prescribed to the patient, which could diminish the size and soften the consistency of the phytobezoar. On day 5, they successfully treated the large duodenal persimmon phytobezoar by using a combination of endoscopic fragmentation and Coca-Cola. Coca-Cola administration is a cheap and easy to perform procedure that can be accomplished at any endoscopy unit. Moreover, endoscopic fragmentation is more efficacious in breaking the phytobezoar and that the combination of Coca-Cola and endoscopic fragmentation is better in dissolving the phytobezoar 15.

References
  1. Chen YC, Liu CH, Hsu HH, Yu CY, Wang HH, Fan HL, et al. (2015). Imaging differentiation of phytobezoar and small-bowel faeces: CT characteristics with quantitative analysis in patients with small-bowel obstruction. Eur Radiol, 25 (4): 922– 31.
  2. Benharroch D, Krugliak P, Porath A, Zurgil E, Niv Y. Pathogenetic aspects of persimmon bezoars. A case-control retrospective study. J Clin Gastroenterol. 1993;17(2):149–152. doi: 10.1097/00004836-199309000-00012
  3. Fu C. Y., Chu C. H., Liu T. P., Hong Z. J., Hsu K. F., Liu Y. C., et al. 2010. The relationship between acid‐suppressing drugs and phytobezoar formation: a retrospective analysis and discussion of phytobezoar formation. Acta Chir. Belg. 110:595–597.
  4. Ripolles T, Garcia-Aguayo J, Martinez MJ, Gil P. (2001). Gastrointestinal bezoars: sonographic and CT characteristics. AJR Am J Roentgenol, 177 ( 1): 65–9.
  5. De Cesare A, Fiori E, Bononi M, Ferraro D. (2015). Phytobezoar-induced small bowel obstruction associated with a concomitant gastric phytobezoar and ulcer in an elderly woman. Ann Ital Chir, 86 ( 1): 70–7.
  6. Gaya J, Barranco L, Llompart A, Reyes J, Obrador A. Persimmon bezoars: a successful combined therapy. Gastrointest Endosc 2002; 55: 581–3.
  7. McKechnie JC. Gastroscopic removal of a phytobezoar. Gastroenterology. 1972;62(5):1047–1051.
  8. Zissin R, Osadchy A, Gutman V, Rathaus V, Shapiro-Feinberg M, Gayer G. (2004). CT findings in patients with small bowel obstruction due to phytobezoar. Emerg Radiol, 10 ( 4): 197–200.
  9. Brogan Kathryn E, Jen K-L Catherine. (2010). Nutrition in the Elderly. In: Handbook of assessment in clinical gerontology. Ed, Lichtenberg Peter A., editor. 2nd ed, Elsevier Inc, pp. 357– 359.
  10. Bedioui H, Daghfous A, Ayadi M, Noomen R, Chebbi F, Rebai W, et al. (2008). A report of 15 cases of small-bowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties. Gastroenterol Clin Biol, 32 ( 6–7): 596–600.
  11. Pergel A, Yucel AF, Aydin I, Sahin DA. Laparoscopic treatment of a phytobezoar in the duodenal diverticulum—report of a case. Int J Surg Case Rep. 2012;3(8):392–394. doi: 10.1016/j.ijscr.2012.03.020
  12. Lee KH, Han HY, Kim HJ, Kim HK, Lee MS. Ultrasonographic differentiation of bezoar from feces in small bowel obstruction. Ultrasonography. 2015;34(3):211–216. doi: 10.14366/usg.14070
  13. Ladas, S. D., Kamberoglou, D. , Karamanolis, G. , Vlachogiannakos, J. and Zouboulis‐Vafiadis, I. (2013), Systematic review: Coca‐Cola can effectively dissolve gastric phytobezoars as a first‐line treatment. Aliment Pharmacol Ther, 37: 169-173. doi:10.1111/apt.12141
  14. Akrami M, Sasani MR. Dietary Habits Affect Quality of Life: Bowel Obstruction Caused by Phytobezoar. Iran J Public Health. 2016;45(8):1080–1082. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139966
  15. Fan S, Wang J, Li Y. An Unusual Cause of Duodenal Obstruction: Persimmon Phytobezoar. Indian J Surg. 2016;78(6):502–504. doi:10.1007/s12262-016-1449-2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5218939
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