A phytobezoar is a type of
bezoar
A bezoar stone ( ) 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 o ...
, 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 insert ...
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, urethr ...
have been reported.
Conditions that lead to decreased motility in the stomach (
gastroparesis
Gastroparesis (gastro- from Ancient Greek – gaster, "stomach"; and -paresis, πάρεσις – "partial paralysis") is a medical disorder of ineffective neuromuscular contractions (peristalsis) of the stomach, resulting in food and l ...
) 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, where the small intestine is rearranged to connect to both. Surgeons have developed several differen ...
) 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 Chinese and Japanese kaki persimmon, ''Diospyros kaki''. In 2022, China produced 77% of the world's p ...
s, which contain a soluble
tannin
Tannins (or tannoids) are a class of astringent, polyphenolic biomolecules that bind to and Precipitation (chemistry), precipitate proteins and various other organic compounds including amino acids and alkaloids. The term ''tannin'' is widel ...
called shibuol that
polymerizes 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 insert ...
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 baskets, snares, or Dormia baskets).
[ If the phytobezoar cannot be removed due to size, electrohydraulic lithotripsy, mechanical lithotripsy, 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 wi ...
(meat tenderizer) and cellulase
Cellulase (; 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 polysaccharides:
: Endo ...
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.]Coca-Cola
Coca-Cola, or Coke, is a cola soft drink manufactured by the Coca-Cola Company. In 2013, Coke products were sold in over 200 countries and territories worldwide, with consumers drinking more than 1.8 billion company beverage servings ...
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 ]gastrotomy
A gastrostomy is the creation of an artificial external opening into the stomach for nutritional support or gastric decompression.
Typically this would include an incision in the patient's epigastrium as part of a formal operation. When originall ...
is required to evacuate the bezoar.[. ''"Operative intervention with a possible gastrotomy or enterotomy is often required to relieve the intestinal obstruction."'']
Physical and chemical properties
Generally, bezoars can be found in the stomach in less than 0.5% of patients having an esophagogastroduodenoscopy.[ The formation of diospyrobezoars from persimmons is due to a chemical reaction between stomach acid and phlobatannin contained in the persimmon.]
References
External links
{{Medical resources
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, ICD10 = {{ICD10, T, 18, , t, 15
, ICD9 = {{ICD9, 938
, ICDO =
, OMIM =
, MedlinePlus = 001582
, eMedicineSubj =
, eMedicineTopic =
, MeshID = D001630
Gastroenterology