Gastric Bezoar /Causes/Symptoms and signs /Diagnosis /Bezoar Removal/ Endoscopic /Surgical/No1doctor

Introduction foreign [Music] [Music] hello everybody today we have a lecture about gastric vesoas doctor can we start now gastric bizarres result from the accumulation of foreign ingested material in the form of masses or concretions bezoars are rare being found in less than one percent of patients undergoing upper gastrointestinal endoscopy in ancient times bizarres from animals were precious and used to cure diseases and as an antidote to poisons Types of Bezoar doctor what are types of bizarre bezoars are classified according to their composition the major types are phytobazors trichobazors and pharmacobazors one phytobazors composed of vegetable matter are the most common type of bezaar the disparozoa persimmon fruit accounts for the majority of cases lupini beans used by healers to treat arthritic pain have also formed a bizarre trichobazors composed of hair usually occur in young women with psychiatric disorders trichotillomania hair pooling and trichophagia hair eating usually precede trichoid formation a small number of patients have been reported in whom the gastric trigonzoir has a long tail and extends throughout the small bowel to the cecum this condition known as the rapunzel syndrome occurs almost exclusively in young girls pharmacobazors composed of ingested medications have become increasingly recognized examples include extended release nifedipine theophylline enteric coated aspirin sodium alginate and sucral fate other bezels composed of a variety of other substances have been described these include milk curd tissue paper shellac fungus styrofoam cups cement and vinyl gloves doctor what is the pathogenesis of Pathogenesis bisours bezoars grow by the continuing ingestion of food rich in cellulose and other indigestible materials such as hair cotton and tissue paper matted together by protein mucus and pectin properties of the specific ingested material and some degree of gastric dysfunction also contribute bezoar formation is rare in healthy subjects it was recognized in 1938 that most patients with bezoars had undergone gastric surgery implying that there are underlying anatomic and functional abnormalities more recent studies have shown that 70 to 94 of patients have a history of gastric surgery and 54 to 80 percent have undergone vagotomy and pyloroplasty it was initially thought that the most common functional abnormality found in patients with bezels was delayed gastric emptying however some studies have found that many patients have normal or accelerated gastric emptying in one series for example gastric emptying was studied in 10 patients who presented with bezel 1 to 20 years after some type of gastric surgery and inoperated patients without bezavas there were no differences between the two groups in gastric emptying of tc 99 meters labelled solids at 45 75 and 105 minutes this implies that the pathogenesis of bezoar formation is more complex than initially thought and involves other factors such as alterations in the production of acid pepsin and mucus and impairments in the grinding mechanism and the interdigestive migrating motor complex the pathogenesis of the persimmon bezel diaspirobezoa is well understood the unripe fruit contains high concentrations of a soluble tannin called shibutal which forms a coagulum when mixed with acid as occurs in the stomach many patients form diaspirobazors without gastric dysfunction trichobazors form in patients with tricholomania and trichophagia they begin as retained hairs between the gastric folds the hair is then denatured by gastric acid becomes black regardless of hair colour and combines with food to form an enmeshed mass trichobazors become colonized by bacteria resulting in a foul smell pharmacobazors occur in a variety of circumstances with the major predisposing factors being gastric dysfunction and the properties of the particular drug as examples bowel hypoactivity dehydration and the concomitant use of anticholinergic agents and opiates contribute to the propensity for bezoar formation in patients with renal failure treated with aluminum hydroxide sucral fate bezos typically occur in patients with gastric outlet obstruction beziers composed of magnesium and calcium carbonate may be seen when compressed tablets are given to patients with a chloride insolubility of the carrying vehicle is the major contributing factor to bezaar formation with enteric-coated aspirin and niphetipine the hydroscopic properties of psyllium and wheat dextrin contribute to the propensity of these compounds to form bezels Clinical Features doctor what are the clinical features of visors most adults with phytobazos are men between the ages of 40 and 50 years while trichobazors are typically seen in women in their 20s affected patients remain asymptomatic for many years and develop symptoms insidiously common complaints include abdominal pain nausea vomiting early satiety anorexia and weight loss it is hard to distinguish symptoms attributable to bezoars from those caused by the underlying condition eg post gastrectomy syndromes gastroparesis etc up to 20 percent of patients continue to have symptoms despite bezel removal gastrointestinal bleeding is a common presentation since there is a high association of gastric ulcers in patients with bezels who undergo surgery the ulcers may be due to peptic ulcer disease or pressure necrosis although many bezels become quite large gastric outlet obstruction is an uncommon presentation visors have rarely been associated with a vast array of other gastrointestinal complications these include gastrointestinal perforation peritonitis protein losing enteropathy stitory pancreatitis interception dysphagia obstructive jaundice appendicitis constipation and pneumotosis intestinalis another rare problem is drug overdose from a pharmacobsar one patient for example presented with a theophylline overdose due to the presence of an unrecognized bezel containing 29 grams of theophylline the residue of many sustained release tablets another patient with an enteric coated aspirin bizarre presented with salicylate toxicity after being given barium for a radiographic study the barium created an alkaline medium which dissolved the pharmacobsar the physical examination is unremarkable in most patients with a gastric bezel except for an occasional abdominal mass or halitosis patients with trichobazors may have patchy areas of alopecia doctor what Diagnosis about the diagnosis of bisours bezoars are usually discovered as an incidental finding in a patient with non-specific symptoms abdominal radiograph with or without barium abdominal ultrasound or ct scan may show the bezel as mass or a filling defect unlike phytobazos which are generally impervious to barium trichobazors tend to absorb barium aiding in the diagnosis the current gold standard for diagnosis is upper gastrointestinal endoscopy it provides direct visualization of the bezel and allows sample taking and therapeutic intervention it is important to sample the bezel for analysis since it may be difficult to determine the composition based upon appearance Treatment doctor what about treatment of visors therapy for bezel should be tailored to the composition of the concretion into the underlying pathophysiologic process available treatment methods include chemical dissolution endoscopy and surgery phytobazors may be chemically dissolved in comparison trichobazors are resistant to enzymatic dissolution and must be removed with either endoscopy or surgery medical therapy chemical dissolution should be considered for phytobazors producing mild symptoms it is also the most effective method when endoscopic extraction of large phytobazors is not possible there are no prospective studies evaluating medical treatment of phytobazors many agents have been tried with success but most trials are uncontrolled and anecdotal the following agents have been used successfully cellulase cellulase tablets can be given with meals to degrade the cellulose and hemocellulose found in plant fiber and phytobazors papain papain is given in the form of a dolph's meat tenderizer one teaspoon in 120 milliliters of water before each meal acetyl cysteine acetylcysteine is instilled 15 milliliters in 50 milliliters of water via nasogastric tube three times daily for several days coca-cola a growing number of reports describe the successful treatment of phytobazors using a nasogastric or oral coca-cola infusion or endoscopic injection of coca-cola the mechanism of coca-cola's action may be related to its low ph the high sodium bicarbonate content and the presence of co2 bubbles in one study coca-cola alone achieved complete bezaar bubbles dissolution of 23.5 percent of patients coca-cola appears to be more effective in dissolving bezels in patients with phytobazors and pharmacobazors metaclopramide is usually used in conjunction with endoscopic mechanical fragmentation and enzymatic therapy in a dose of 10 milligrams orally before meals and at bedtime in one study nine patients treated with adjunctive therapy required a mean of 1.2 courses of endoscopic therapy while 15 patients treated with endoscopic therapy alone required 1.9 courses of treatment cellulase appears to be preferred over papain because of side effects associated with papane one study reviewed existing published reports a treatment of 36 patients with phytobazors with papain and cellulase papain was successful in treating 13 of 15 patients and cellulase was successful in 19 of 19. adverse effects in the papain group included gastric ulcer and esophageal perforation while no adverse effects were reported in the patients treated with cellulase a potential complication of successful enzymatic therapy is that dissolved bizarres may cause small bowel obstruction endoscopy trichobazors and dyspirobazors are treated with endoscopic and surgical techniques endoscopic removal involves fragmenting the bezoar with waterjet direct suction through a large channel six millimeters endoscope forceps and snares and then clearing the fragments with the endoscope ewold tube or passive passage through the gastrointestinal tract a variety of other methods have been described in case reports when the above techniques have failed including use of the nd yag laser endoscopic drills and mechanical electrohydraulic extracorporeal lithotripsy an injection of enzyme solutions or coca-cola surgery surgical removal should be considered in patients who fail medical therapy or who have complications such as obstruction and significant bleeding initial surgical therapy has also been recommended in vessels composed of vinyl gloves in such cases endoscopic removal may be difficult or impossible because the gloves become hardened and matted doctor what about the prevention removal of the bezel does not alleviate the underlying problem preventive therapy should be implemented to avoid a reported 14 recurrence rate patients should be encouraged to ingest increased water intake to appropriately alter the diet eg avoid persimmons and stringy vegetables to chew food carefully and to seek psychiatric evaluation if needed for trichobazors treating an underlying motility problem may be useful as a preventive measure in some patients Summary Recommendations doctor what about summary and recommendations gastric bizarres result from the accumulation of foreign ingested material in the form of masses or concretions bezoars grow by the continuing ingestion of food rich in cellulose and other indigestible materials such as hair cotton and tissue paper matted together by protein mucus and pectin bezoars are classified according to their composition the major types are phytobazors trichobazors and pharmacobazors type phytobazors composed of vegetable matter are the most common type of bizarre trichobazors composed of hair usually occur in young women with psychiatric disorders pharmacobazors are composed of ingested medications the pathogenesis of bizarre formation is complex and involves factors such as delayed gastric emptying alterations in the production of acid pepsin and mucus and impairments in the grinding mechanism and the interdigestive migrating motor complex affected patients remain asymptomatic for many years and develop symptoms insidiously common complaints include abdominal pain nausea vomiting early satiety anorexia and weight loss gastrointestinal bleeding is a common presentation bezoars are usually discovered as an incidental finding or in a patient with non-specific symptoms abdominal radiograph with or without barium abdominal ultrasound or ct scan may show the bezel as a mass or a filling defect the gold standard for diagnosis is upper gastrointestinal endoscopy therapy for bezel should be tailored to the composition of the concretion and to the underlying pathophysiologic process for patients with a phytoebsi are producing mild symptoms we suggest initial treatment with cellulase grade 2c other agents that can aid in bezoar dissolution include papain acetylcysteine and coca-cola metaclopramide is prescribed in conjunction with these agents trichobesors and diaspirobazors are treated with endoscopic and surgical techniques surgical removal should be considered in patients who fail medical therapy or who have complications such as obstruction and significant bleeding Outro thanks dr atef for excellent presentation thanks for watching our video hope to see you again in more next videos please subscribe to youtube channel number one doctor with my best wishes doctor atef ahmed [Music] you