Bezoars are conglomerates that cannot be digested and are trapped in the gastrointestinal tract. According to previous studies, bezoars have a relatively low prevalence, ranging from approximately 0.068% to 0.43% [1,2]. Bezoars are classified based on their composition: phytobezoars, composed of undigested plant materials; trichobezoars, consisting of ingested hair; lactobezoars, formed from solidified milk or formula; pharmacobezoars, caused by the accumulation of medications; and paper bezoars, resulting from the ingestion of paper or other indigestible materials. These masses can lead to symptoms including abdominal pain, nausea, and vomiting, potentially leading to emergency conditions such as gastrointestinal obstruction or perforation [3]. The optimal treatment for bezoars has not been established; however, depending on each individual case, various approaches such as the use of chemicals including Coca-Cola, endoscopic fragmentation, and surgical treatment have been employed either independently or in combination [4]. With recent advancements in endoscopic treatment techniques, surgical intervention for bezoars has become less common. However, treatment can be challenging when the bezoar is large or particularly hard. Herein, we describe a case in which a large bezoar was successfully removed at a community healthcare facility using conventional endoscopic methods combined with chemical dissolution.

A 60-year-old male presented with dyspepsia and epigastric pain that had persisted for more than 2 months. The patient had a history of type 2 diabetes mellitus (DM) and was currently receiving oral hypoglycemic agents, including metformin and sitagliptin. In addition, he had undergone repair surgery for a duodenal ulcer perforation in his 20s.

One month before visiting our center, he underwent an upper endoscopy at another facility. The patient was aware of the presence of a gastric ulcer and foreign materials in the stomach but lacked definitive evidence, as no test results were provided.

The patient’s vital signs were within normal ranges: blood pressure, 128/70 mm Hg; heart rate, 67 beats per minute; respiratory rate, 18 breaths per minute; temperature, 36.2°C. An acutely ill appearance was noted during the physical examination, along with mild tenderness in the upper abdomen. No abnormalities were found upon examination of the other systems. Blood test results showed a white blood cell count of 9300/mm³, hemoglobin level of 15.8 g/dL, hematocrit of 46.9%, and platelet count of 296000/mm³, with no anomalies in chemistry or electrolyte panels.

We planned to repeat the upper endoscopy and performed abdominopelvic computed tomography (APCT) for further evaluation of epigastric pain. APCT revealed a solid material measuring 10 cm×8 cm in the gastric lumen, suggestive of a bezoar (Fig. 1). Endoscopic examination revealed a large bezoar measuring approximately 10 cm in size in the fundus, which extended along the upper body of the stomach (Fig. 2A). It contained fibers and seeds, indicating that it was a phytobezoar. Additionally, a 1.5 cm sized active gastric ulcer was observed at the gastric angle, which was probably caused by pressure from the bezoar (Fig. 2B). The patient had previously undergone surgery for duodenal perforation, but no structural abnormalities were observed during endoscopy. Attempting to grasp the bezoar with biopsy forceps revealed that its surface was extremely hard and smooth, making it resistant to capture and impossible to fragment. After the completion of the initial examination, the patient was admitted for further care. Upon re-taking the patient’s history, it was noted that the patient had recently consumed persimmons, which are considered a major contributing factor in bezoar formation. To facilitate chemical dissolution, Coca-Cola was administered orally and endoscopic fragmentation was planned for three days later. The patient was instructed to consume 1 liter of Coca-Cola per day, for a total of 3 liters over three days. No specific time for consumption was designated; instead, the patient was advised to drink it at his convenience, ensuring that the full 1 liter was consumed within the day.

During the second endoscopy session, the bezoar had softened slightly after ingestion of Coca-Cola. Initially, a crack was created in the center of the bezoar using biopsy forceps. Subsequently, electrical damage was induced through the crack using hot biopsy forceps and an electrosurgical unit (ERBE VIO 300D; Erbe Elektromedizin GmbH, Endocut Q mode: Effect 2, Interval 3, Duration 3). As the current flowed into the bezoar, the bezoar split into two pieces (Fig. 3). However, the bezoar remained too large to be captured with a polypectomy snare. Consequently, the second session was concluded, and the patient was discharged with plans to revisit one week later and continue treatment as an outpatient. Based on past treatment experience alone, we had not considered adding other agents beyond Coca-Cola administration. However, given its limited effectiveness in dissolving the gastric bezoar, we decided to explore additional pharmacological treatment options. Among the options, we decided to add cellulase, which was readily available for immediate administration to the patient. Therefore, the patient was instructed to consume approximately 1 liter of Coca-Cola per day, along with a digestive enzyme supplement containing cellulase (Festal Plus; HANDOK Inc., 2 tabs TID). Rabeprazole 20 mg twice daily was prescribed for ulcer treatment.

In the third session, the bezoar had softened significantly, allowing easy fragmentation using the biopsy forceps. The dissolution effect was greater when cellulase was combined with Coca-Cola, compared to when Coca-Cola was used alone. Various devices were tried to expedite the fragmentation process, including rat tooth forceps (Radial Jaw 4 Standard Capacity; Boston Scientific), a 4-prong grasper (Foreign Body Removing Forceps; MTW) and a polypectomy snare (BMA Co., Ltd.) (Fig. 4A-C). The 4-prong grasper proved to be the fastest at breaking down the material. Once the bezoar was reduced to pieces <3 cm, it was completely captured using a polypectomy snare. Subsequently, a combination of the polypectomy snare and the 4-prong grasper was used to further reduce the pieces to less than 1 cm in size. Larger clump-like fragments were removed as much as possible (Fig. 4D). The procedure lasted approximately one hour.

The patient continued to take rabeprazole 20 mg once daily, and a follow-up upper endoscopy one month later revealed complete disappearance of the bezoar and healing of the gastric ulcer (Fig. 5).

Phytobezoars are the most common type of bezoar, a finding consistent with research conducted in South Korea [4]. The known risk factors for bezoar formation include a history of gastric surgery, high fiber diet, chewing difficulties, and DM [5,6]. The most frequent clinical symptoms seen in patients with bezoars include nausea, vomiting, epigastric pain, dyspepsia, and weight loss [6]. Bezoars can lead to complications such as ulceration, bleeding, bowel obstruction and perforation. Therefore, accurate and prompt diagnosis and management of patients with bezoars is essential to prevent the development of severe complications [7]. The management of bezoars varies depending on factors such as size, composition, location, and any accompanying pathology. Presently, treatment options encompass dissolution using chemical compounds including Coca-Cola, papain, pepsin, cellulase, and acetylcysteine; endoscopic fragmentation and extraction; and surgical procedures [8]. Coca-Cola is the most commonly employed chemical agent for the dissolution of phytobezoars. Some studies have reported successful removal of bezoars using Coca-Cola. However, there is no consensus on the method and dosage [2,8,9]. The precise mechanism by which Coca-Cola dissolves bezoars remains unclear. However, Coca-Cola has a pH of 2.6, similar to stomach acid, which may activate proteolytic enzymes in the stomach and enhance dissolution. Furthermore, carbon dioxide gas and sodium bicarbonate produced in Coca-Cola may infiltrate the bezoar, assisting in the digestion of its fibrous components [10]. According to a previous report, pharmacological treatment with cellulase has some effectiveness [11,12]. One case series reported successful pharmacological treatment by administering Coca-Cola and cellulase (cellulase Thera-blend 6000 units/day) simultaneously over a period of 1–2 months [11]. In our case, Coca-Cola was used initially, followed by the sequential addition of cellulase (60 mg/day). A key difference from previous reports is that this approach allowed for an indirect comparison of the therapeutic effects of monotherapy and combination therapy with the two agents. We observed greater dissolution effects when Coca-Cola was combined with cellulase compared to when Coca-Cola was used alone. However, these pharmacological treatments are limited by their low success rate and prolonged duration, making them inadequate when used alone. And also, the dosage and enzyme activity of cellulase differ between manufacturers, so there is no standardized dosage or regimen for the treatment of bezoars established to date. As the stomach is the most common site for bezoars, endoscopic methods have become the primary treatment approach. Mechanical fragmentation can be accomplished using a variety of devices, including biopsy forceps, polypectomy snares, argon plasma coagulation devices, electrosurgical knives, laser devices, and electrohydraulic lithotripsy [13]. In some reports, effective endoscopic fragmentation of bezoars has been performed using a custom-made novel large-sized snare or by inserting snares onto guidewires to form a larger-sized lithotripsy device [14,15].

In cases where the bezoar is large and hard, outpatient clinics or community hospitals often refer the patients to tertiary hospitals with specialized equipment, such as lithotripsy baskets or electrohydraulic lithotripsy, which are available for surgical intervention. However, in our case, we successfully removed a large bezoar through three sessions of endoscopic procedures using conventional devices commonly available in most healthcare facilities. Furthermore, since the combination therapy of Coca-Cola and cellulase showed good dissolution effects, it may serve as evidence for recommending combination pharmacological therapy with agents known to promote dissolution as adjunctive treatments for bezoars. If the patient’s overall condition is stable and they can tolerate repeated endoscopic procedures, treatment may be feasible even in smaller healthcare institutions.

In conclusion, we report a case in which a large bezoar was successfully removed through pharmacological treatment including Coca-Cola and cellulase, as well as endoscopic treatment using conventional devices, in a community healthcare facility.