Foreign Bodies and Bezoars
Ingestion of foreign bodies is a problem because of the tendency for small children to put everything into their mouths. There may or may not be history of ingestion of a foreign body. If a foreign body does not become stuck in the duodenum or at the first part of the small intestine (ligament of Treitz), it ordinarily passes through the intestinal tract. A foreign body that perforates the intestine may produce obstruction.
Bezoars are masses in the stomach or intestines that are formed from hair or other material. Trichobezoars (bezoars made of hair) usually are seen in mentally retarded or emotionally disturbed patients. Most patients with bezoars of their own hair are teenage girls. The presentation is one of intestinal obstruction. Plain films of the abdomen, sometimes supplemented by upper gastrointestinal contrast studies with small bowel follow-through where the patient swallows dye and it followed as it passes through the stomach and the intestines are usually diagnostic. Trichobezoars ordinarily obstruct the stomach, duodenum, and upper jejunum. Phytobezoars, which are made of vegetable matter, usually obstruct the distal (last part) ileum, but also may obstruct the stomach, particularly after vagotomy. Phytobezoars in the stomach may be broken apart by an endoscope pushed into the stomach via the mouth. This process may be facilitated by introduction of pancreatic enzymes. Concretions related to use of sodium polystyrene sulfonate (Kayexalate), cholestyramine, or calcium- containing antacids usually obstruct the last part of the intestine and colon. At times a distinct mass (lump) can be felt on abdominal examination of the patients.
Trichobezoars that become obstructive must be treated operatively by removal of the hair. Care must be taken to remove the entire bezoar because this can fragment on removal. In instances of obstructing plugs from other causes, if they cannot be dislodged by washing through a tube or an endoscope, operative removal generally is required. Colostomy may be needed in patients with colonic obstruction.
Another form of obstruction is caused by parasites, which generally block the middle and downstream small bowel. Ascaris lumbricoides is the most common parasite involved. If the obstruction cannot be relieved by the administration of antihelminthic agents, operation may be required.
The long-term outlook is generally good, provided that the underlying disorder that resulted in formation of the bezoar is managed appropriately. Psychosocial issues often need to be addressed in children with trichobezoars to prevent reoccurrence.
Articles and graphics adapted from O'Neill: Principles of Pediatric Surgery. © 2003, Elsevier.