Ingested foreign bodies occur most often in children under the age of 3 years, in patients with psychiatric disorders, in patients who use excess alcohol and drugs, among convicts, and in denture wearers. More than 99 per cent of ingested foreign bodies are asymptomatic: the principal risk associated with foreign body ingestion in children is oesophageal impaction and injury. More than 95 per cent of objects that reach the stomach pass through the gastrointestinal tract without ill effect, and guilt and anxiety of the parents often require more attention than does the child who has swallowed an object. The role of the surgeon is to identify the occasional patient in whom surgical treatment is needed. The history may or may not be reliable, depending upon parental observation of objects held by the infant. The majority of potentially harmful objects are radio-opaque. Radiographs should encompass the entire gastrointestinal tract from pharynx to anus. Non-radio-opaque objects may be further localized using contrast studies. Endoscopy is useful to differentiate intragastric objects from neoplasms.

Foreign bodies in asymptomatic patients for the most part should be allowed to progress through the gastrointestinal tract spontaneously, monitored by serial radiographs. Foreign bodies are frequently missed on stool examinations, which are not usually sufficiently assiduous. Unless a particular object has a known capacity for causing mischief, or outpatient observation is not reliable, children need not be kept in hospital.

The indications for operative removal of gastric foreign bodies include: signs of obstruction, perforation, or bleeding; accumulation of multiple foreign bodies in the stomach; certain large or long sharp objects; objects known to result in toxicity; failure of the foreign body to leave the stomach, and impaction.

Gastric outlet obstruction due to a foreign body is not encountered as frequently as is small bowel obstruction. Haemorrhage may occur following local mucosal ulceration at the site of impaction. Ulceration secondary to prolonged foreign body retention usually heals once the foreign body is removed. Perforation of the stomach and duodenum often presents as a fistula into adjacent organs, including the liver in the case of gastric perforations and the right kidney or inferior vena cava in the case of sharp objects in the adjacent duodenum. Late perforations complicating toothpick, chicken, or fishbone ingestion are insidious and associated with much morbidity; they are rarely identified preoperatively.

Smooth objects are innocuous in the stomach, and considerable patience should be exercised to permit their passage. Even remarkably large objects such as scissors or tableware can pass through the gastrointestinal tract in the adult. Gastric retention of foreign bodies may be related to pre-existing pyloric stenosis. If after 4 weeks the object remains, or if the object is larger than the duodenal loop, or long and sharp, removal using fibreoptic endoscopy is indicated. A variety of grasping forceps and snares have been devised for removal. For ferrous metal objects successful removal using a magnet attached to a nasogastric tube is useful in paediatric patients, and anaesthesia is not required. Endoscopic removal carries the risk of oesophageal damage or impaction upon withdrawal; endoscopic devices should be equipped with a protective sheath drawn over the object at the time of withdrawal. One might argue that if a foreign body can be safely extracted by endoscopy it can usually be left to pass naturally.

Objects likely to cause perforation or impaction include those that are long, sharp, and pointed, such as open safety pins or hair grips in children under 2 years, toothpicks, needles, and toothbrushes, as well as objects with a configuration likely to prevent passage thorugh the pylorus or through the second portion of the duodenum. Of all gastrointestinal tract perforations due to foreign body one-quarter to one-half occur in the stomach or duodenum. Alkaline disc batteries are innocuous unless there is radiographic evidence of disruption of the battery case, which may result in leakage and caustic damage to the stomach wall. In the case of narcotic packet ingestion for purposes of smuggling, endoscopic removal is contraindicated as intragastric breakage of the package may prove fatal (Fig. 1) 952.

If endoscopic removal fails or there is evidence of obstruction, perforation, or bleeding, surgical gastrotomy should be performed. It is important to obtain an immediate preoperative film to be sure that the object has not migrated. Removal of non-impacted duodenal foreign bodies may be simplified by manually replacing the object into the stomach; otherwise duodenotomy is necessary. If multiple foreign objects are present the small bowel should always be examined.

Bezoars are concretions of ingested material, originally described in animals. They are of considerable historical and now clinical interest. Bezoar is a transliteration of the Arabic badzehr or the Turkish panzehr, meaning antidote. The oriental bezoar is found in the stomach and intestine of the bezoar goat Capra aegagyrus or that of the gazelle, Antelope dorcas. Bezoar stones were prized until the eighteenth century as cures for a variety of diseases—a largebezoar stone set in gold was included in the inventory of the crown jewels at the time of the ascension of James I to the English throne in 1662.

The classification of bezoar into four types is somewhat arbitrary in that the term is usually reserved for concretions of ingested food or chemicals; high fibre food boluses are close relatives.

Trichobezoars consist of a mass of ingested hair combined with other fibres, and usually occur in young women (90 per cent), including some with psychiatric difficulties. The hair forms a black cast of the stomach with a glistening mucoid appearance and a foul odour (Fig. 2) 953.

The most common type of phytobezoar, concretions of botanic origin, occur following the ingestion of persimmons (Diospyros virginiana). In the south-eastern United States this bezoar occurs typically in hunters who eat this fruit when unripe. Related members of the same genus are found in Israel, Japan, Korea, India, and Zimbabwe. Unripe persimmons contain large amounts of a soluble phlobatannin which coagulates in the stomach to form a tenacious glue that entraps fibres. This type of bezoar is also known as a ‘diospyrobezoar’. A second common type of phytobezoar follows ingestion of citrus fruits, although an immense variety of other vegetable matter has also been implicated. Incompletely chewed citrus segments are hygroscopic and expand in the small bowel, sometimes causing obstruction. Trichophytobezoar is a combination of the two forms mentioned above.

Bezoars may also be formed by concretions of medications or chemicals. The shellac bezoar occurs in furniture workers who imbibe an alcoholic solution of shellac; the shellac precipitates in the stomach, particularly when this cocktail is followed by water. The relative incidence of neonatal lactobezoar and antacid bezoar has increased, the former being associated with prematurity, and the latter with intensive antacid therapy in high-risk hospital inpatients, particularly those in renal failure.

Factors predisposing to bezoar formation include both diet and pre-existing gastroduodenal pathology. In addition to the binge eating of persimmons or citrus fruits, monotonous high fibre diets during famine or following periods of religious fast or at harvest time in the tropics may produce bezoars. During the past several decades the most common form of bezoars in developed countries has been found in patients who have undergone gastric surgery. These phytobezoars, 90 per cent of which are composed of citrus fruits, occur several months to many years after any surgical procedure with the potential for altering gastric emptying. They occur in 5 to 14 per cent of postgastrectomy patients. Postgastrectomy bezoars occur in patients with poor dentition, high fibre intake, reduced gastric acid production and gastric stasis with or without partial gastric outlet obstruction. An increased incidence of bezoar may also occur in patients with diabetic gastroparesis or other neurological conditions affecting the stomach, such as autonomic neuropathy and myotonic dystrophy.

Gastric bezoars may be asymptomatic and found only incidentally. When symptoms occur they are due to the size of the bezoar and its complications—most commonly obstruction, and less often bleeding or perforation. Large masses may cause a sensation of epigastric fullness and early satiety. Nausea, vomiting, and abdominal pain are common due to the size of the mass or obstruction, or associated ulceration. Gastric outlet obstruction is uncommon in phytobezoar but can certainly cause partial outlet obstruction after gastrectomy. However, small bowel obstruction due to migration or fragmentation of a gastric bezoar is common. Obstruction may follow attempts at endoscopic fragmentation. Intestinal obstruction due to bezoar is seen in patients with an intact gastrointestinal tract, as well as in those who have undergone gastric surgery.

Patients with a large trichobezoar may suffer weight loss, anaemia, gastrointestinal bleeding, and obstructive symptoms. Trichobezoars may extend from the stomach into and through the entire small intestine, the so-called ‘Rapunzel syndrome’. A history of trichophagia may be elicited. The physical findings include palpable epigastric mass, alopecia, and halitosis. ‘Daughter’ trichobezoars may result in intestinal obstruction. Gastric ulceration with haemorrhage or frank perforation due to trichobezoar carries significant mortality.

Bezoars may be visible on plain films as mottled densities in the left upper quadrant. Phytobezoars are frequently missed (75 per cent) during contrast studies: they appear as a mobile foreign body of varying size that may become infiltrated with barium. Trichobezoars form a cast of the stomach outlined with barium. Small bowel bezoar is occasionally seen directly on plain films, but more commonly the findings are those of small bowel obstruction; the bezoar may be identified on antegrade contrast studies of the small bowel.

The principal differential diagnosis of gastrobezoar is neoplasm, particularly when the bezoar is fixed in position. Endoscopy can serve to differentiate the two; bezoars are often discovered incidentally at endoscopy performed during evaluation of symptoms following gastrectomy. Endoscopy should be undertaken in all cases of suspected bezoar to detect associated abnormalities, as gastroduodenal ulceration is present in 10 to 40 per cent of patients.

Uncomplicated gastric phytobezoar can usually be managed without operation. Digestion of the bezoar using repeated doses of oral cellulase has greater reported success rates (>83 per cent) than the use of the proteolytic enzyme papain or the mucolytic agent acetylcysteine. Gastric emptying may be promoted by the use of metoclopramide. Occasionally simple gastric lavage is sufficient. If these measures are unsuccessful, bezoars may be fragmented and removed endoscopically using biopsy forceps or stone baskets, or disrupted using streams of water. Ulcerations at the site of an impacted bezoar usually heal following removal of the foreign body, although bezoars can occur in patients with pre-existing ulceration at the gastric outlet. Surgical gastrotomy is reserved for patients with large phytobezoars or those that are symptomatic. In contrast, trichobezoar should always be managed surgically (Fig. 2) 953, as conservative measures and endoscopy are of no avail; untreated trichobezoar carries a significant morbidity and mortality. Prophylactic antibiotics should be given; trichobezoars are typically putrefied.

Small bowel bezoars are treated surgically if obstruction supervenes. At laparotomy, attempts should be made to advance the bezoar into the colon manually. If these efforts are unsuccessful, enterotomy and extraction are necessary. One must guard against the not infrequent occurrence (4 to 17 per cent) of multiple bezoars by examining the stomach and the entire small bowel at laparotomy. Preoperative endoscopy is of value in cases of small bowel obstruction due to bezoar in order to identify unsuspected gastric or duodenal bezoar and extract or fragment these if possible, as they may be readily missed upon attempted palpation at laparotomy when there has been previous gastric surgery.

After successful bezoar removal, attention must be directed towards prevention of recurrence. Intake of high fibre foods, especially citrus fruits, should be avoided and adequate dentition assured. Chronic prophylactic oral enzyme therapy and the use of metoclopramide may reduce the incidence of recurrence. Tachyphylaxis to metoclopramide is rapid, however. The paradox of the bezoar is that while they were treasured in antiquity, much effort now is spent in ridding ourselves of them.

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