Bezoars: An unusual cause of intestinal obstruction in children

Intestinal obstruction in children are mostly caused by congenital anomalies of the gastrointestinal tract. Ingested foreign bodies can cause GI disturbance including obstruction. Bezoars are concretions of human or vegetable fi bers that accumulate in the gastrointestinal tract. The most common type of bezoar in human is the trichobezoar, which is mostly made of hair, followed by bezoars made of vegetable or fruit fi ber (phytobezoars), milk curd (lactobezoars), or any indigestible material. Intestinal obstruction due to bezoars is an uncommon cause of intestinal obstruction among children and adolescents. We present seven cases of intestinal obstruction in children and young adults caused by bezoars between 2012 and 2019. The age ranged from 11 months to 16 years. There were four females to three males. One adolescent girl had trichobezoars, another had tricho-phytobezoars, three had phytobezoars and two had lactobezoars. The presentations were epigastric discomfort, nausea, intestinal obstruction, chronic malnutrition, recurrent vomiting and abdominal distension. One adolescent girl with Rapunzel syndrome, required psychiatric treatment following removal of the trichobezoar. All the children except one required surgery. A child with lactobezoar improved with conservative treatment and passed the bezoar after enema. All the operated patients had uneventful recovery. The mean follow up was 83.5 months. Research Article Bezoars: An unusual cause of intestinal obstruction in children Hemonta KR Dutta1, Mauchumi Baruah2* and Debasish Borbora3 1MS, M.Ch, Professor, Department of Pediatric Surgery, India 2MD, Associate Professor, Department of Physiology, Assam Medical College & Hospital, Dibrugarh, Assam, India 3PhD, Assistant Professor, Gauhati University, Assam, India Received: 08 May, 2021 Accepted: 10 June, 2021 Published: 11 June, 2021 *Corresponding author: Dr. Mauchumi Baruah, MD, Associate Professor, Department of Physiology, Assam Medical College & Hospital, Dibrugarh, Assam, India, E-mail:


Introduction
Bezoars are concretions of human or vegetable fi bers that accumulate in the gastrointestinal tract. Although bezoars are most commonly found in the stomach, they can be found anywhere in the gastrointestinal (GI) tract [1]. The most common type of bezoar in human is the trichobezoar, which is mostly made of hair, followed by bezoars made of vegetable or fruit fi ber (phytobezoars), milk curd (lactobezoars), or any indigestible material. Intestinal obstruction in children is mostly caused by congenital anomalies of the gastrointestinal tract. Bezoars is an uncommon cause of intestinal obstruction among children and adolescents. We present seven cases of intestinal obstruction in children and young adults caused by bezoars between 2012 and 2019.

Seven children & adolescents presenting with intestinal
obstruction and other GI disorders between 2012 and 2019 are presented. There were three males and four females (Table 1). Age ranged from 11 months to 16 years (median= 88 months; mean = 96.3 months). The common presenting symptoms were epigastric discomfort, nausea, recurrent vomiting, abdominal distension, constipation and bilious vomiting. One adolescent girl had history of trichotillomania (pulling out her own hair) and trichophagia (eating her hair) ( Figure 1). Another 13 year old girl had trichophytobezoar, but she gave no history of trichophagia. Both these girls had poor nutritional status and required psychiatric treatment following surgery. Three patients had phytobezoar and two had lactobezoars. Five patients presented with features of acute intestinal obstruction. Six patients needed surgery and all of them had uneventful recovery. One patient improved with conservative treatment and had passed the bezoar rectally after an enema. The mean follow up was 83.5 months.

Discussion
Bezoars are defi ned as aggregates of undigested or inedible Citation: Dutta  An altered gastric physiology, such as impaired gastric emptying or reduced acid production, is a well-known cause of bezoars. Bezoars are usually caused by previous gastric operations, such as vagotomy or partial gastrectomy, and can also be caused by gastroparesis or a gastric outlet obstruction [7]. The initial presentation of a bezoar often depends on its composition. Lactobezoars may present in premature infants or newborns with symptoms of feeding intolerance, abdominal distension, irritability, and/or vomiting. Physical examination may reveal a palpable abdominal mass in these patients. Simpsons [8] noted that pharmacobezoars can present with symptoms of gastric outlet obstruction, and    and ultrasonography (USG). Detection rate of trichobezoars by USG was reported to be around 88% [14]. Upper gastrointestinal series can demonstrate a fi lling defect in the stomach, however, this procedure has the risk of causing obstruction or perforation.
CT scan demonstrates heterogeneous masses containing trapped air bubbles or homogenous mottled appearance in the region of stomach or intestine [14]. For gastric bezoars, endoscopy remains the investigation of choice [15].
Treatment of bezoars involve surgical removal of the bezoar and prevention of recurrence. Although surgical removal has been considered the standard treatment option for gastrointestinal bezoar, increasing use of endoscopy for diagnostic and therapeutic purposes has been reported with a success rate ranging from 50% to as high as 100% [16][17][18]. Apart from surgical removal, a wide range of therapeutic options have been used, including acetylcysteine, papain, metoclopramide, cellulase, and even instillation of Coca-Cola [17][18][19][20][21][22][23]. However, adverse effect of some of these therapies have been reported [24]. Blam