Gastric barium sulfate bezoar: clinical observation

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Introduction

According to the International Classification of Diseases, modern medicine classifies pathologies associated with the presence of bezoars in the gastrointestinal tract under the foreign body section under codes T18.0, T18.2, T18.3, and T18.4. A bezoar is a specific formation that develops in the stomach and is often referred to as a gastric or bezoar stone. The etymology of the term goes back to the Arabic badzahr (where bad means “wind” and zahr means “poison”), which is translated as “protecting from poison,” or to the Chaldean combination of “bel” (lord) and “zaar” (poison). Bezoars remain relatively rare in medical practice, and the disease itself, known as bezoar disease (morbus bezoaris), is not widely known among medical professionals [1].

Studies of bezoars have shown that stones or dense masses in the gastrointestinal tract appear as a result of indigestible objects entering it: hair, hard-to-break-down elements of medicines, fragments of seeds, peel, chewing gum, high-calorie baby formula, and other elements that have entered the stomach and have not been digested by gastric juice and enzymes, but instead have stuck together to form a conglomerate, creating non-mineral compounds that are only conditionally called stones. Foreign and undigested residues begin to be covered with layers of mucus, forming hard “stones”. This process can be compared to the formation of pearls in a mollusk, which tries to neutralize a foreign object that has entered it. The first description of bezoar in humans was made by Baudomant in 1779 during the autopsy of a patient who died of gastric perforation and peritonitis, and the first surgical removal of bezoar was performed by Shonbern in 1883. Until 1991, about 400 cases of bezoar disease were described in the world literature [2–5].

Stomach bezoars are composite materials formed in the stomach from food and non-food components when ingested, mixing with gastric chyme, consisting of two or more heterogeneous components which, when combined, create a new material with unique properties that are not simply the sum of the properties of the original elements. Depending on their origin, medical literature distinguishes more than 10 types of bezoars, the most common of which are [3; 6]: phytobezoars (formed from plant components such as the peel and seeds of fruits and vegetables; a separate subgroup is diospyrobezoars from persimmons); trichobezoars (formed from swallowed hair and wool); sebaceous bezoars (from swallowed animal fat); picoid bezoars (containing resinous substances); shellac bezoars (bitumen or tar stones); anthracobezoars (from coal particles); mineral bezoars (from chalk deposits); hematobezoars (consisting of blood clots); mycobezoars (from fungal elements); lacto-bezoars (include undigested milk); medicinal bezoars (from magnesium and barium sulfate compounds, other drugs). If groups are identified for each individual observation with a unique composition of bezoar, the list may turn out to be extensive, despite the rarity of bezoar disease.

The formation of bezoars can be triggered by various factors. The main predisposing conditions include: mental disorders, insufficient chewing of food, problems with evacuation of stomach contents, high fiber content in the diet, excessive amount of viscous gastric secretion in gastritis, complications after stomach surgery. The rate of bezoar formation varies from several days to several years and depends on the nature of the diet, the state of the motor function of the stomach, secretory activity, and the presence of intestinal pathologies [5].

Bezoars can take various forms under the influence of the motor-evacuation activity of the gastrointestinal tract (GIT): round, ovoid, sausage-shaped, or triangular.

They are classified by size as follows [6]:

• small (up to 5 cm) – can leave the digestive tract naturally or with appropriate treatment;
• medium (6–8 cm) – create obstacles to the movement of contents, although the passage of liquid and semi-liquid chyme is maintained;
• large (9–14 cm) – capable of causing almost complete obstruction of the gastrointestinal tract, may be complicated by: ulcerative lesions, bedsores, perforation of organ walls, metabolic disorders, bleeding of varying intensity;
• gigantic (more than 15 cm) – pose a particular danger due to their size and require immediate medical attention.

The multifactorial nature of the process of bezoar formation determines the diversity of the clinical picture of the disease [7]. The clinical manifestations of bezoars in the gastrointestinal tract are nonspecific and are determined by several important factors: the type of formation, its size, location, and duration of presence in the stomach. The disease begins with subtle symptoms, but as the bezoar grows, characteristic signs appear: a feeling of heaviness in the upper abdomen, aching pain after eating, stomach discomfort, nausea and vomiting, loss of appetite, rapid satiety, and weight loss. In thin patients, large bezoars can be felt through the front wall of the abdomen as dense formations in the stomach area, which sometimes leads to a misdiagnosis of cancer.

There have been cases in medical practice where giant bezoars weighing up to 1 kg and formations measuring up to 30 cm in the stomach have been found. A gastric trichobezoar that constantly increases in size, with its tail reaching the small intestine, is called Rapunzel syndrome, named after the princess from the Brothers Grimm fairy tale [4; 5; 7; 8].

Instrumental diagnosis of bezoar disease includes: ultrasound examination (US), X-ray of the stomach, fibrogastroduodenoscopy, computed tomography [9]. Ultrasound reveals a voluminous formation with uneven contours, high echogenicity with acoustic shadowing, which requires differential diagnosis with stomach tumor. X-ray examination of the stomach reveals a round or oval-shaped filling defect with a heterogeneous structure, gas bubbles, and dense inclusions of undigested fiber. Fibrogastroduodenoscopy is the most informative diagnostic method, which allows for an accurate diagnosis, helps determine the nature of the bezoar, and assesses the condition of the mucous membrane. Computed tomography allows for accurate localization of the bezoar and detects formations at any level of the gastrointestinal tract.

In urgent cases, the symptoms of gastrointestinal bezoars can simulate other diseases, such as acute pancreatitis, intestinal obstruction, and duodenostasis. Possible complications of bezoars include: stomach erosion and ulcers, bleeding, stomach wall perforation and peritonitis, small intestine obstruction [5; 10–13]. Treatment depends on the size and clinical manifestations of the bezoar and may include: conservative methods, minimally invasive interventions, surgical treatment.

Small bezoars can leave the body on their own with vomit or naturally. For phytobezoars, a 10% soda solution can be effective, helping to break down the formation and promote its natural removal.

In 2002, Japanese doctors reported the successful treatment of stomach bezoars with Coca Cola – the stones dissolved completely or could later be removed by crushing. For some patients, it was sufficient to drink 3 liters of the beverage over a period of 12 hours, while others drank it for 2 months. In the literature, the effect of the beverage is explained by the presence of orthophosphoric acid and bubbles of dissolved CO₂, which penetrate deep into the bezoar, as well as the mucolytic effect of NaCO₃ [5].

Bezoars of plant origin that do not respond to conservative treatment, as well as trichobezoars, sebaceous bezoars, pico bezoars, and shellac bezoars, should be removed endoscopically after being crushed with ultrasound or “chunked” [5; 14]. The ineffectiveness of attempts to fragment and remove the bezoar in pieces is an indication for laparotomy, gastrotomy, followed by removal of the bezoar. In addition, urgent surgery is performed in the event of intestinal obstruction [5; 15].

Materials And Methods

Five patients with gastric bezoars were under our observation at the First Republican Clinical Hospital in Izhevsk: two patients with persimmon bezoars, one with a bezoar that had formed in an operated stomach, one with a barium sulfate bezoar, and one patient with a tooth gold crown found in the center of the bezoar. In the available literature, we found only one description of a barium sulfate bezoar [16]. Therefore, we considered it appropriate to share our clinical observation.

Infrared Fourier spectroscopy of a foreign body in the stomach was performed using an FSM 2201 device. IR Fourier spectroscopy is a universal analysis method that allows the composition of various materials to be determined. It can be used to detect the presence and concentration of both organic and inorganic substances in different physical states. The method has a wide range of applications: from analyzing food products and soil to studying metals, their alloys, polymer materials, and pharmaceuticals. The principle of operation is based on the ability of substances to absorb infrared radiation. Each substance forms its own unique set of frequency ranges—an absorption spectrum that can be compared to a “fingerprint” at the molecular level. This spectrum is a characteristic feature of a specific chemical compound, which allows its presence in the sample under investigation to be accurately identified.

Clinical Case

Female patient V., 58 years old, was admitted to the surgical department of the First Republican Clinical Hospital of the Ministry of Health of the Udmurt Republic, Izhevsk, on March 11, 2024, with a diagnosis of acute biliary-alcoholic pancreatitis. Upon admission, she complained of moderate pain in the right hypochondrium, epigastric and umbilical regions, nausea, and periodic vomiting of stomach contents. She fell acutely ill on February 2, 2024, with intense aching pain in her right upper hypochondrium, then throughout her abdomen. Prior to this, she had abused alcohol and experienced jaundice, faeces acholia, and a rise in body temperature to 38°C. She was treated in the surgical department of the Central District Hospital until February 9, 2024, where an ultrasound revealed stones in her gallbladder. For further treatment, she was transferred to an interregional hospital, where she remained until March 11, 2024, with a diagnosis of “subtotal aseptic pancreonecrosis. Parapancreatic infiltrate. Obstructive jaundice”. Formation of a pancreatic cyst. Gallstone disease, chronic calculous cholecystitis. Jaundice resolved during treatment, well-being improved, body temperature normalized. According to ultrasound and CT scan data, a fluid formation developed in the head of the pancreas. Palpation of the epigastric region revealed an infiltrate measuring 8.0 × × 15.0 cm, which was painful, immobile, and with questionable fluctuation. The patient was offered surgical treatment. Laparoscopic sanitation and drainage of the omental bursa, partial necrosectomy performed (March 13, 2024). From March 15, 2024, the patient began to complain of increased nausea and vomiting of fluids and stomach contents mixed with bile. From 17.03.2024, vomiting became frequent. Given the frequent vomiting, a Schwartz test with barium sulfate was prescribed and performed to examine transit. On 19.03.2024, the contrast remained in the stomach for 24 hours (Fig. 1).

 

Fig. 1. Schwarz`s test

 

Given the gastric paresis (persistent gastroparesis), it was decided to perform a laparotomy, revision, and, if necessary, abscess drainage. A sequester measuring 2.0 × 3.0 cm was removed from the head of the pancreas during the operation. Intestinal peristalsis was sluggish. During further revision, a dense foreign body was found in the lumen of the stomach, freely movable. A gastrotomy was performed, and a foreign body resembling a stone, light gray-yellow in color and measuring 6.0 × 4.0 × 4.0 cm, was removed from the stomach cavity—most likely caked barium sulfate (petrified barium suspension) (Fig. 2).

 

Fig. 2. Removed barium sulfate bezoar

 

The gastrotomy wound was sutured with a double row of stitches. Physicists and chemists from Udmurt State University were called in to perform a qualitative and quantitative analysis of the stone removed from the stomach. Infrared Fourier spectroscopy was performed on the foreign body.

Results and Discussion

The result of the molecular composition analysis of the foreign body removed from the patient's stomach was 99 % barium sulfate.

Barium sulfate is commonly used for X-ray examination of the gastrointestinal tract and to study passage. It has been widely used since the early 20th century and can be administered orally or rectally. Barium itself is a strong adsorbent, so it is coated with substances such as methylcellulose to keep it in suspension. Modern preparations contain combinations of polysorbate 80, sodium saccharin, sodium benzoate, and benzoic acid. Barium deposition in the mucous membrane of the colon was first described as barium granuloma in 1954 by Beddo et al. In most cases, barium sulfate is excreted in the stool without complications. In patients with clinical symptoms of intestinal obstruction, barium sulfate may contribute to an additional risk of obstruction. In addition, there have been rare reports of acute appendicitis following irrigoscopy, known as “barium-induced appendicitis”, possibly due to a delay leading to obstruction of the appendix lumen [17]. We can assume that two factors triggered the formation of a sulfate barium bezoar in the stomach of the patient we observed: dehydration due to repeated vomiting and decreased motor function of the stomach and intestines against the background of dynamic paralytic obstruction in acute infected pancreonecrosis.

Conclusions

1. In cases of clinical signs of intestinal obstruction and dehydration, barium sulfate may contribute to an additional risk of obstruction.
2. Do not recommend performing the Schwartz test in patients with clinical signs of gastrointestinal motility disorders and repeated vomiting. Use radiopaque aqueous solutions to examine the passage of intestinal contents.
3. Fourier transform infrared spectroscopy provides conclusive evidence for determining the molecular composition of a foreign body sample in the gastrointestinal tract.

About the authors

V. V. Pronichev

Izhevsk State Medical Academy

Email: AnnaVLed@ya.ru
ORCID iD: 0000-0002-8379-7224

DSc (Medicine), Professor, Head of the Department of Faculty Surgery

Russian Federation, Izhevsk

M. N. Klimentov

Izhevsk State Medical Academy

Email: AnnaVLed@ya.ru
ORCID iD: 0000-0002-0005-7686

PhD (Medicine), Associate Professor of the Department of Faculty Surgery

Russian Federation, Izhevsk

A. V. Ledneva

Izhevsk State Medical Academy; First Republican Clinical Hospital of the Ministry of Health of Udmurt Republic

Author for correspondence.
Email: AnnaVLed@ya.ru
ORCID iD: 0000-0003-3871-6197

PhD (Medicine), Assistant of the Department of Faculty Surgery

Russian Federation, Izhevsk; Izhevsk

References

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