Clinical Outcomes of Patients With Gastric Phytobezoars: Implication of Drinking Carbonated Beverages as a Treatment

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Korean J Helicobacter Up Gastrointest Res. 2024;24(3):259-266

Publication date (electronic) : 2024 September 9

doi : https://doi.org/10.7704/kjhugr.2024.0032

Jin Ook Jang, Cheol Woong Choi, Dae Gon Ryu, Su Bum Park, Su Jin Kim

Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea

Corresponding author Cheol Woong Choi, MD, PhD Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea E-mail: luckyace@hanmail.net

Received 2024 May 3; Revised 2024 May 24; Accepted 2024 June 3.

Abstract

INTRODUCTION

A bezoar is a conglomeration of indigestible materials within the gastrointestinal tract, resulting from the accidental ingestion of various substances. The incidence of gastric bezoars reported in endoscopic examinations ranges from 0.43%–0.68% [1,2]. Although bezoars can be found in any part of the gastrointestinal tract, the stomach is the most commonly affected site. Most gastric bezoars are dissolved and discharged without treatment. However, they can occasionally cause gastric ulceration and bleeding [3], and can also migrate to the small intestine and cause mechanical obstructions. Bezoars represent a rare cause of small bowel obstruction; among patients surgically treated for mechanical small bowel obstruction, 0.8% of cases were associated with bezoars [4]. Therefore, removal of gastric bezoars should be considered in cases of large bezoars (>3 cm) or in symptomatic patients [5,6].

Although the majority of gastric bezoars comprise plant materials, such as fibers, skins, or seeds of vegetables and fruits (phytobezoars), ingested hair (trichobezoar), medications (pharmacobezoar formation due to bulk-forming laxatives, extended-release tablets, or enteric-coating drugs), and other ingested foreign bodies may also result in gastric bezoars [3,7]. The primary predisposing factor for gastric bezoars is delayed gastric emptying. Gastric dysmotility and reduced acid secretion may induce gastric bezoar formation. Conditions associated with gastric dysmotility or decreased gastric acid secretion include previous gastric resection, vagotomy, peptic ulcer disease, advanced age, Crohn disease, and diabetic neuropathy [8,9]. Moreover, there have been reports indicating that certain ingested materials are more prone to cause bezoars [10-13].

Unfortunately, a standardized method for treating gastric phytobezoars has not been adopted. Surgical removal should be attempted in cases with complications such as massive gastrointestinal bleeding or gastrointestinal obstruction. However, outside of emergency situations, chemical lysis using carbonated beverages, proteolytic enzymes, and cellulases has been employed, either alone or in conjunction with endoscopic bezoar removal [3,14-16]. In this study, we reviewed the clinical outcomes and safety of various gastric phytobezoar treatment methods, particularly the consumption of carbonated beverages prior to therapeutic endoscopy.

METHODS

Patients

A review of medical records and endoscopic reports revealed 15 patients with gastric phytobezoars who were admitted to Pusan National University Yangsan Hospital, South Korea between September 2008 and May 2016. The data were analyzed retrospectively (Fig. 1). This study was reviewed and approved by the Institutional Review Board of Pusan National University Yangsan Hospital. The requirement for written informed consent was waived due to the retrospective nature of this study.

Fig. 1.

Flowchart of the course of the study and the treatment of gastric phytobezoars.

Treatment method

All gastric phytobezoars were diagnosed following endoscopic examinations. Abdominal computed tomography (CT) was performed to exclude intestinal obstructions in patients with abdominal pain and vomiting. Surgical removal was recommended for patients who initially presented with symptoms of small bowel obstruction. For patients with gastric phytobezoars, without evidence of intestinal obstruction, chemical dissolution through carbonated beverage consumption (Coca-Cola) was initially attempted. Patients eligible for chemical dissolution were instructed to drink carbonated beverages (Coca-Cola, 1.5–3 L/day) for 1–2 days.

Each patient underwent repeat endoscopy after consuming the carbonated beverage. If the patient was initially examined in the emergency department, endoscopy was performed daily, except on holidays, until the gastric bezoar resolved. If the initial visit was an outpatient visit, follow-up endoscopy was performed at 1–2 week intervals.

If the phytobezoars remained in the stomach, endoscopic removal of the bezoar was attempted using various endoscopic devices, including electrohydraulic lithotripsy and net and polypectomy snares (Fig. 2). If the endoscopic maneuvers failed to remove the bezoars or if the patient’s symptoms worsened, the bezoars were surgically removed. If the gastric bezoars disappeared after carbonated beverage consumption, without endoscopic treatment or complications, the patient was included in the successful carbonated beverage treatment group. However, if a patient required endoscopic or surgical removal of a small bowel obstruction due to a migrated bezoar, the patient was included in the carbonated beverage treatment failure group.

Fig. 2.

Endoscopic images of a persimmon bezoar. A: A large brown bezoar observed in the gastric body. B: A peptic ulcer observed in the gastric antrum. C: Performance of the electrohydraulic lithotripsy procedure. D: A hole observed after electrohydraulic lithotripsy. E: Fragmentation of the bezoar was performed using polypectomy snares. F: Visualization of the fragments. G: A hard bezoar observed before Coca-Cola administration. H: Direct injection of Coca-Cola into the bezoar. I: Softening of the bezoar following Coca-Cola infusion, facilitating subsequent crushing.

To identify factors associated with treatment outcomes, we retrospectively examined patients’ sex, age at diagnosis, history of intra-abdominal surgery, symptoms, complications, and modalities used to treat the bezoars. The bezoar size was determined using endoscopic imaging, CT, or by measuring extracted specimens. After successful treatment, regular endoscopic follow-ups were recommended for all patients. The first endoscopic examination was scheduled two months after successful treatment. Thereafter, endoscopic examinations were scheduled annually in the absence of recurrence.

RESULTS

Characteristics of patients and bezoars

A total of 15 patients with gastric phytobezoars were included in this study. The mean age of the patients was 71.3±11.1 years, and the patients were predominantly female (8/15, 53.3%). The mean bezoar size was 47.3±14.5 mm. The most prevalent symptoms were epigastric pain (7/15 patients, 46.7%) and bloating (6/15 patients, 40.0%). A history of intra-abdominal surgery was identified in 4/15 (26.7%) of the patients (Tables 1 and 2).

Table 1.

Summarized characteristics of patients with gastric phytobezoars

Table 2.

Analysis of baseline characteristics of patients with phytobezoars

Treatment outcomes

A flowchart depicting the course of the study is shown in Fig. 1. The treatment methods were as follows: drinking the carbonated beverage alone (n=7, 46.7%) and drinking the carbonated beverage in conjunction with endoscopic fragmentation and removal (n=5, 33.3%). Three patients (n=3, 20.0%) experienced small bowel obstructions that were treated surgically (Table 3). All cases of small bowel obstruction were attributed to migrating gastric bezoars following carbonated beverage consumption, with or without endoscopic fragmentation.

Table 3.

Outcomes of gastric phytobezoar treatments

The group that was successfully treated with the carbonated beverage had a gastric and duodenal ulcer prevalence of 57.2% (n=4), compared to 100% (n=8) of the patients in the group that was not successfully treated with the carbonated beverage. A comparison of the baseline characteristics between the carbonated beverage treatment success and failure groups revealed no statistically significant differences (Table 4). There is some concern that carbonated beverages may increase acidity in the digestive tract; however, no serious complications, such as ulcer bleeding, have been observed in patients with peptic ulcers who consume carbonated beverages [17,18].

Table 4.

Comparison between carbonated beverage treatment success and failure groups

DISCUSSION

Gastric bezoars are rarely encountered clinically, but when encountered, phytobezoars are the most common. Phytobezoars are formed from indigestible food materials, such as celery, pumpkins, grape skins, prunes, raisins, and persimmons. In particular, persimmon phytobezoars are challenging to treat due to their hardness compared with other types of phytobezoars [19].

Gastric phytobezoars may be encountered incidentally during routine endoscopies or as a result of an endoscopic examination of a symptomatic patients. However, the optimal treatment approach remains uncertain due to a lack of a consensus regarding the most effective treatment method. For small gastric bezoars, a conservative observational approach may be appropriate because spontaneous passage or dissolution may occur. However, additional treatment modalities may be necessary for gastric bezoars that present symptomatically or are associated with peptic ulceration. In the present study, gastric and duodenal ulcerations were identified in 53.3% (8/15) and 26.7% (4/15) of the cases, respectively. A total of 93.3% of patients exhibited symptoms, including bloating, epigastric pain, and nausea.

To date, the following treatment methods have been identified for phytobezoars. Chemical dissolution, using carbonated beverages or enzymes such as papain and cellulase, is a common treatment method for phytobezoars. In recent years, several studies have been conducted on the use of carbonated beverages for the dissolution of gastric phytobezoars [3,16,20]. In the present study, we used Coca-Cola as the therapeutic carbonated beverage. Here, 46.7% of the patients with gastric phytobezoars experienced spontaneous resolution after drinking the carbonated beverage over a 24–48-hour period. More than half of the patients with gastric bezoars that persisted after the consumption of the carbonated beverage (n=8) were successfully treated with additional endoscopic procedures (n=5). Including patients treated with the carbonated beverage alone (n=7, 46.7%) and with an additional endoscopic therapy (n=5, 33.3%), 80% of the patients (n=12) were successfully treated.

Previous studies have demonstrated that the resolution rate of phytobezoars using carbonated beverages, with or without endoscopic maneuvers, was 84.0%–91.3% [14]. However, during treatment with carbonated beverages that dissolve phytobezoars, migration of small or fragmented bezoars may cause small bowel obstruction. In the present study, small bowel obstructions occurred in 20.0% (n=3) of the patients who consumed carbonated beverages. The use of carbonated beverages as a treatment for phytobezoars was first introduced in 2002 by Ladas et al. [14,21] Following the publication of the initial study report, numerous subsequent studies have demonstrated the efficacy of carbonated beverages for the treatment of gastric phytobezoars [3,16,20]. In addition to carbonated beverages, chemical dissolution agents, such as papain and cellulase, can also be used. Papain, a proteolytic enzyme extracted from Carica papaya, hydrolyzes a wide variety of proteins. A recent study showed that papain was effective in the treatment of proteinaceous esophageal food impaction without complications [22]. However, esophageal perforation, aspiration pneumonitis, and hemorrhagic pulmonary edema have been reported as potential complications associated with the use of proteolytic enzymes [23]. Although the exact mechanism is unknown, these complications are suspected to arise due to the non-target action of such proteolytic enzymes [24,25]. Another useful enzyme is cellulase, which degrades the cellulose that is abundant in vegetables and fruits; therefore, it may be useful for phytobezoar treatment [15]. Additionally, there are also reports of the use of acetylcysteine to treat bezoars, although the literature on it is limited [26-28].

Although the exact mechanism of action of carbonated beverages is not fully understood, the actions of its ingredients are likely contributory: sodium bicarbonate is mucolytic, carbonic and phosphoric acids have an acidifying effect, and carbon dioxide bubbles penetrate the bezoar through microscopic pores [14,19]. A recent in vitro study reported on the dissolution of phytobezoars by chemical dissolution agents. The study showed that chemical dissolution agents (Coca-Cola, papain, and cellulase) were more effective at dissolving phytobezoars than the control (water). Further, Coca-Cola was more effective than papain and cellulase [25]. If a phytobezoar is resistant to the aforementioned chemical dissolution methods, endoscopic fragmentation and removal may be considered. Despite the favorable factors associated with the use of carbonated beverage dissolution (ease, cost, and effectiveness), clinicians should be aware of the possibility of small bowel obstruction due to the migration of fragments of or the whole gastric bezoars, which can occur up to six weeks after migration from the stomach [14]. Consequently, patients should be meticulously monitored for symptoms indicative of small bowel obstruction, such as vomiting and abdominal discomfort, throughout the follow-up period. In cases where such symptoms manifest, CT should be performed.

In the present study, small bowel obstruction occurred in 20.0% (n=3) of the patients following carbonated beverage therapy. Various methods can be employed for endoscopic fragmentation, including the use of endoscopic forceps, polypectomy snares, water jets, neodymium:yttrium-aluminum-garnet lasers, extracorporeal shockwave lithotripsy, and endoscopically guided electrohydraulic lithotripsy. Endoscopic treatment of bezoars is essentially a mechanical crushing process that can be achieved using a variety of instruments available at the institution, including forceps, lithotripters, snares, and argon plasma coagulation [29-32]. Because of the risk of migration, bezoar fragments should be removed during the endoscopic procedure, if possible.

A well-known gastric phytobezoar that is refractory to the aforementioned treatment modalities is the persimmon bezoar. The skin of unripened persimmons contains a high concentration of tannins that react with gastric acid, and then polymerize to form a conglomeration in which cellulose, hemicellulose, and various proteins accumulate [33]. In this study, only one patient was diagnosed with a persimmon gastric bezoar.

In general, delayed gastric emptying, with or without decreased gastric acid secretion, is the mechanism of gastric bezoar formation. A variety of conditions may be predisposing factors, including certain ingested materials such as persimmons, advanced age, diabetic neuropathy, prior gastrectomy history, Crohn disease, gastrointestinal malignancy, dehydration, hypothyroidism, and the use of medications (such as anticholinergics and narcotics) [3,8,9]. In the present study, most patients were of older age, with a mean age of 71.3 years, and 26.7% of the patients (n=4) had a history of intra-abdominal surgery.

We compared the carbonated beverage treatment success and failure groups to evaluate the factors that increased the risk of treatment failure. Although, there was no significant difference between the two groups, the patients who failed the carbonated beverage treatment were older (76.0 years vs. 66.0 years) with larger bezoar sizes (51.9 mm vs. 42.1 mm) than the successful treatment group’s patients. In our study, one patient with a bezoar was asymptomatic (the bezoar was identified during a routine health screening examination), demonstrating that gastric phytobezoars can be observed in asymptomatic patients. However, most patients were symptomatic, with the most common symptoms being epigastric pain (n=7) and bloating (n=6). Several methods, including endoscopy and CT, can be used to diagnose gastrointestinal bezoars. Endoscopy may be the most useful diagnostic method because it allows direct visualization. In CT images, a phytobezoar can be identified as a round mass containing air bubbles. Furthermore, CT is an essential imaging modality, especially when surgery is considered, as it permits visualization of the obstructed segment of the bowel and identification of multiple bezoars [34].

This study had several limitations. First, it was conducted retrospectively in a single center and included a small number of cases. Furthermore, we could not evaluate recurrence rates, as the majority of the patients did not adhere to the recommended follow-up examinations or hospital visits. The relapse rate has been reported to be as high as 14%, especially in patients with psychiatric conditions or gastrointestinal dysmotility [35]. In this study, although only four patients (26.7%) returned for follow-up visits; there was no evidence of recurrence during the 12–35 months following successful treatment.

To prevent the recurrence of gastrointestinal phytobezoars, we recommend not consuming stringy vegetables or persimmons and instructed the patients to chew their food thoroughly. Prokinetics such as erythromycin may be used in patients with gastric dysmotility.

In conclusion, this study demonstrated that 80% of patients with gastric phytobezoars were successfully treated with carbonated beverages alone or in conjunction with additional endoscopic management. However, small bowel obstructions occurred in 20% of the patients due to the migration of a fragmented bezoar. Given the potential for bezoar migration and subsequent complications, clinicians should educate patients about the possibility of bowel obstructions before recommending carbonated beverage treatment, with or without endoscopic treatment. During endoscopic procedures, the fragmented bezoars should be removed, if possible.

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