Oral Pharmacologic Agents Associated with Medication Bezoar:
FormationBezoars are collections of indigestible material that accumulate in the GI tract, most frequently in the stomach. The 3 most common types of bezoars encountered are phytobezoars, composed of vegetable matter; trichobezoars, made up of hair or hair-like fibers; and medication bezoars (pharmacobezoars).
•Smaller bezoars may be treated with conservative medical management; usually this consists of a liquid diet for a short period of time and a prokinetic agent to promote gastric emptying. Chemical dissolution, most commonly with cellulase, has been reported successful in up to 85% of patients with small bezoars. Cellulase can be taken as a tablet or instilled into the stomach as a liquid via an endoscope or nasogastric tube.Nasogastric lavage may aid in the physical dissolution of small bezoars. Carbonated soda (e.g., Coca-Cola) may be effective in the dissolution of over 50% of cases of phytobezoars and over 90% when combined with endoscopic methods. Additional medications that have been shown to effectively treat gastric bezoars include pancreatin and ursodeoxycholic acid, alone or in combination with cellulase and carbonated beverages.
•For larger bezoars and bezoars resistant to medical therapy, endoscopic therapy may be effective. The endoscope is used to fragment the bezoar into smaller pieces. Fragmentation can be performed with the endoscope itself, with accessory devices like forceps or snares, or with instillation of saline or water flushesthrough the endoscope. The fragments of the bezoar can be pushed into the small bowel or removed by mouth. If most of the bezoar is to be removed, an overtube is recommended to facilitate frequent passes of the endoscope and to protect the airway. Mechanical disruption and endoscopic removal will be successful in 85% to 90% of gastric bezoars. Resistant gastric bezoars may be treated with mechanical lithotripsy, electrohydraulic lithotripsy, Nd : YAG laser, or a needle-knife sphinctertome.
•Operative intervention may be needed if endoscopic therapy fails or if there is a complication related to the bezoar (e.g., perforation, obstruction,bleeding). Trichobezoars more often require surgery than phytobezoars. Gastric bezoars are usually removed via a small gastrostomy. Small bowel bezoars are removed via an enterotomy or can be transmurally milked to the cecum, where they rarely cause a problem in the larger-diameter colon.
•Laparoscopic removal can first be attempted in bezoar removal but conversion to an open surgery may occur in just over half of patients. When operative intervention is contemplated, care must be made to exclude multiple bezoars in more than one location.
𝗣𝗿𝗲𝘃𝗲𝗻𝘁𝗶𝗼𝗻 𝗼𝗳 𝗿𝗲𝗰𝘂𝗿𝗿𝗲𝗻𝗰𝗲:
Preventing bezoar recurrence is as important as active treatment. If the underlying causes of bezoar formation are not corrected, recurrence is likely. Avoidance of high-fiber and other non-digestible foods should be followed. A starting dose of cellulase, an enzymatic dissolution medication, can be taken prophylactically by patients who have frequently recurring bezoars. Prokinetic drugs may be useful for patients with underlying motility disorders. In particularly refractory patients with recurring gastric bezoars, repeated periodic endoscopy with physical disruption of food material may prevent larger and clinically significant bezoar formation.