Gastrointestinal bezoars are a common condition both in daily life and in clinical practice. They arise when a person eats foods that readily form concretions; the resulting signs vary with the size and consistency of the mass. Careful, step-by-step evaluation is therefore essential to avoid misdiagnosis or delayed diagnosis and the added morbidity these errors entail.
Diagnostic work-up
History
Recent intake of persimmon, hawthorn, or black jujube followed by epigastric pain, repeated vomiting, or melena should raise immediate suspicion. Confirmation is obtained endoscopically and/or radiologically.
Laboratory tests
- Microcytic hypochromic anaemia in some patients
- Positive faecal occult blood; early stools may contain persimmon-skin-like debris
- Gastric acid analysis: free acid often higher than normal
Imaging & endoscopy
- X-ray (barium meal or double-contrast)
– Barium stream is diverted; a free-floating, round/oval filling defect is seen on top of the barium pool.
– Mucosal pattern is intact and the wall remains pliable.
– After gastric emptying, streaky, reticular or patchy barium still clings to the mass, which changes shape and position when compressed, indicating compressibility and mobility. - Gastro-duodenoscopy (first-line procedure)
– Directly visualises colour (yellow, brown, green, black) and shape (single or multiple spheres, “J”-shaped or kidney-shaped).
– Phytobezoars are usually yellow-brown; trichobezoars are black/dark-brown and may extend into the duodenum.
– Permits biopsy of bezoar fragments and of any accompanying gastritis or ulcer. - Ultrasonography
– After 500–1000 mL water, a well-demarcated strongly echogenic mass is seen floating in the fluid layer and shifting with posture or peristalsis.
Differential diagnosis
- Functional dyspepsia – dyspeptic symptoms but negative endoscopy/barium study.
- Chronic gastritis – irregular upper-abdominal pain; endoscopy shows chronic antral changes.
- Zollinger–Ellison (gastrinoma) – BAO > 15 mmol/h, BAO/MAO > 0.6, atypical/multiple refractory ulcers, diarrhoea, serum gastrin > 200 pg/ml (often > 500).
- Malignant gastric ulcer/gastric cancer – excluded by endoscopy with biopsy and barium study.
- Prolapse of gastric mucosa – intermittent pain unrelieved by antacids but eased by left lateral decubitus; barium may show a “mushroom” or “parachute” defect in the duodenal bulb.
Because bezoars can masquerade under many guises, active prevention is vital: regular exercise, balanced meals, careful eating habits and avoidance of foods known to precipitate concretions will minimise the risk and keep the gastrointestinal tract clear.
| Category | Key points (English) |
|---|---|
| Clinical suspicion | Recent persimmon / hawthorn / black-jujube intake + epigastric pain, vomiting, melena. |
| Laboratory tests | Microcytic anaemia; + faecal occult blood; persimmon-skin debris; ↑ gastric free acid. |
| X-ray barium study | Free-floating round/oval filling defect on barium pool; mucosa intact; mass compressible & mobile; residual barium clings after emptying. |
| Endoscopy (1st-line) | Direct view of colour/shape; distinguishes phytobezoar vs trichobezoar; allows biopsy; detects gastritis / ulcer. |
| Ultrasonography | After 500–1000 mL water: strongly echogenic mass floating in gastric fluid, shifts with posture/peristalsis. |
| Differential diagnoses | 1. Functional dyspepsia – symptoms only, negative imaging. 2. Chronic gastritis – endoscopy shows antral changes. 3. Zollinger–Ellison – high BAO, multiple atypical ulcers, ↑ serum gastrin. 4. Malignancy – ruled out by endoscopy + biopsy. 5. Gastric mucosal prolapse – intermittent pain, “mushroom” defect on barium. |
| Prevention advice | Regular exercise; balanced low-oxalate, high-fiber diet; chew food thoroughly; limit bezoar-promoting fruits (persimmon, hawthorn, etc.). |