A phytobezoar is a type of

bezoar A bezoar is a mass often found trapped in the gastrointestinal system, though it can occur in other locations. A pseudobezoar is an indigestible object introduced intentionally into the digestive system. There are several varieties of bezoar, s ...

, or trapped mass in the gastrointestinal system, that consists of components of indigestible plant material, such as fibres, skins and seeds. While phytobezoars may be discovered incidentally on barium x-ray or

endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inse ...

testing of the stomach, individuals with phytobezoars may develop symptoms: nausea, vomiting,

gastric outlet obstruction Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that ha ...

, perforation, abdominal pain, and

bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

have been reported. Conditions that lead to decreased motility in the stomach (

gastroparesis Gastroparesis (gastro- from Ancient Greek γαστήρ – gaster, "stomach"; and -paresis, πάρεσις – "partial paralysis"), also called delayed gastric emptying, is a medical disorder consisting of weak muscular contractions (peristalsis) ...

) and surgeries on the stomach (such as vagotomy or

gastric bypass Gastric bypass surgery refers to a technique in which the stomach is divided into a small upper pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect to both. Surgeons have developed several differ ...

) are associated with the development of phytobezoars. A specific type of phytobezoar, termed a diospyrobezoar, is associated with ingestion of unripe

persimmon The persimmon is the edible fruit of a number of species of trees in the genus '' Diospyros''. The most widely cultivated of these is the Oriental persimmon, ''Diospyros kaki'' ''Diospyros'' is in the family Ebenaceae, and a number of non-per ...

s, which contain a soluble

tannin Tannins (or tannoids) are a class of astringent, polyphenolic biomolecules that bind to and precipitate proteins and various other organic compounds including amino acids and alkaloids. The term ''tannin'' (from Anglo-Norman ''tanner'' ...

called shibuol that

polymerizes In polymer chemistry, polymerization (American English), or polymerisation (British English), is a process of reacting monomer molecules together in a chemical reaction to form polymer chains or three-dimensional networks. There are many for ...

into a coagulative cellulose-protein compound in the acid environment of the stomach, to form the bezoar. In addition to their presence in human stomachs, phytobezoars have been documented in the stomachs of slaughtered plant-eating animals.

Cause

Gastric phytobezoars are a form of intestinal blockage and are seen in those with poor gastric motility. The preferred treatment of bezoars includes different therapies and/or fragmentation to avoid surgery. Phytobezoars are most common and consist of undigested lignin, cellulose, tannins, celery, pumpkin skin, grape skins, prunes, raisins, vegetables and fruits. Phytobezoars can form after eating persimmons and pineapples. These are more difficult to treat and are referred to as diospyrobezoars. Phytobezoars are more likely to form due to the ingestion of raw plant foods, even in persons without predisposing factors, as cooking softens them for easier digestion.

Treatment

Several treatments for phytobezoars have been described.

Endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inse ...

involves using a fibre-optic flexible camera to identify the phytobezoar, that can be evacuated from the stomach using various assisted devices (such as

Roth basket Roth may refer to: Places Germany * Roth (district), in Bavaria, Germany ** Roth, Bavaria, capital of that district ** Roth (electoral district), a federal electoral district * Rhineland-Palatinate, Germany: ** Roth an der Our, in the district ...

s, snares, or Dormia baskets). If the phytobezoar cannot be removed due to size, electrohydraulic

lithotripsy Lithotripsy is a non-invasive procedure involving the physical destruction of hardened masses like kidney stones, bezoars or gallstones. The term is derived from the Greek words meaning "breaking (or pulverizing) stones" ( litho- + τρίψω r ...

, mechanical

, snares, or Nd:YAG laser therapy may be used to fragment the mass.

Papain Papain, also known as papaya proteinase I, is a cysteine protease () enzyme present in papaya (''Carica papaya'') and mountain papaya (''Vasconcellea cundinamarcensis''). It is the namesake member of the papain-like protease family. It has wide ...

(meat tenderizer) and

cellulase Cellulase (EC 3.2.1.4; systematic name 4-β-D-glucan 4-glucanohydrolase) is any of several enzymes produced chiefly by fungi, bacteria, and protozoans that catalyze cellulolysis, the decomposition of cellulose and of some related polysaccha ...

enzymes have been used to help reduce the size of phytobezoars. Carbonated soda ingestion has also been found to be useful to decrease the size of diospyrobezoars. A systematic review regarding initial treatment of phytobezoars with

Coca-Cola Coca-Cola, or Coke, is a carbonated soft drink manufactured by the Coca-Cola Company. Originally marketed as a temperance bar, temperance drink and intended as a patent medicine, it was invented in the late 19th century by John Stith Pembe ...

found that Coca-Cola alone completely dissolved phytobezoars in half of cases, and that Coca-Cola combined with other endoscopic methods (particularly endoscopic fragmentation) was successful more than 90% of the time. The same review found that diospyrobezoars (which are considered more difficult to dissolve because of their hard consistency) were successfully treated with Coca-Cola alone in only 23% of cases, but that follow-up endoscopic fragmentation was successful in 84.6% of cases in the publications reviewed. When all other measures have failed, surgical

gastrectomy A gastrectomy is a partial or total surgical removal of the stomach. Indications Gastrectomies are performed to treat stomach cancer and perforations of the stomach wall. In severe duodenal ulcers it may be necessary to remove the lower porti ...

is required to evacuate the bezoar.

Physical and chemical properties

Generally, bezoars can be found in the stomach in less than 0.5% of patients having an

esophagogastroduodenoscopy Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered ...

. The formation of diospyrobezoars from persimmons is due to a chemical reaction between stomach acid and phlobatannin contained in the persimmon. Tannin and shibuol found in the skin of unripe persimmons reacts with gastric acid and forms a coagulum. This structure then accumulates cellulose, hemicellulose and protein.

References

External links

{{Medical resources , DiseasesDB = 30758 , ICD10 = {{ICD10, T, 18, , t, 15 , ICD9 = {{ICD9, 938 , ICDO = , OMIM = , MedlinePlus = 001582 , eMedicineSubj = , eMedicineTopic = , MeshID = D001630 Gastroenterology