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Introduction: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is not certain whether quetiapine IR overdose would similarly cause a delayed increase in serum quetiapine concentrations., Case Report: A 57-year-old woman with depression who was taking half a tablet of 25 mg quetiapine IR daily was transported to our emergency department with a complaint of disturbance of consciousness 12 h after a quetiapine IR overdose. On arrival, her initial vital signs were heart rate of 116 beats per minute, blood pressure of 77/43 mm Hg, and oxygen saturation of 91% under 10 L oxygen administration. Whole body plain computed tomography showed a large amount of gastric hyperdense content suggesting pharmacobezoar with a volume of 71.2 ml. After treatment with respiratory and circulatory support, gastric lavage was performed. Her disturbance of consciousness persisted until day 5, and she was extubated on day 7. The serum concentrations of quetiapine were 2690 ng/mL at 12 h after overdose, 5940 ng/mL at 40 h, and 350 ng/mL at 124 h after overdose. Serum concentrations of other co-ingestions were all below lethal levels., Conclusion: A massive quetiapine IR overdose with pharmacobezoars can cause a delayed increase in serum quetiapine concentrations., (© 2024. American College of Medical Toxicology.)

Aim: To analyze efficacy of endoscopic lithotripsy combined with drug lithotripsy as compared with drug lithotripsy for the treatment of phytobezoars., Methods: We collected and evaluated case records of 165 patients with phytobezoars from 2014 to 2023. And we analyzed demographic and clinical characteristics, imaging features, endoscopic features, complications of phytobezoars, and compared efficacy between endoscopic lithotripsy combined with drug lithotripsy (Group A) and drug lithotripsy (sodium bicarbonate combined with proton pump inhibitor) (Group B)., Results: The median age of patients with phytobezoars was 67.84 ± 4.286 years old. Abdominal pain was the most common symptom and peptic ulcers (67.5%) were the most common complication. Bezoar-induced ulcers were more frequent in the gastric angle. The success rate of phytobezoars vanishing in Group A and Group B were similar (92.3% vs. 85.1% within 48 h, 98.7% vs. 97.7% within a week), while the average hospitalization period, average hospitalization cost, second endoscopy rate, and average endoscopic operation time were significantly lower in patients in Group B than in Group A., Conclusion: Drug lithotripsy is the preferred effective and safe treatment option for phytobezoars. We advise that an endoscopy should be completed after 48 h for drug lithotripsy., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Introduction: the administration of enteral nutrition through a nasogastric tube can cause potentially serious complications. We present a case of esophageal obstruction due to an enteral nutrition bezoar. Case report: the 77-year-old patient was admitted to our center in the intensive care unit for COVID pneumonia. The patient received enteral nutrition through a nasogastric tube (NGT), presenting difficulty passing it after a month of follow-up. After removal of the tube and attached to it, an esophageal mold for enteral nutrition was extracted. Later, a solvent solution is administered through a new SNG and the formula is modified for a hydrolyzed one. Discussion: enteral nutrition bezoars are a rare but can be a life-threatening complication.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

We herein report a very unusual case of small bowel obstruction caused by phytobezoar in a 69-year-old woman who consumed a large amount of bracken. The patient presented with nausea and vomiting. Computed tomography revealed an air-filled foreign body in the jejunum that had likely caused the small bowel obstruction. A fibrous foreign body diagnosed as a phytobezoar was detected using double-balloon enteroscopy. The obstruction was successfully resolved by crushing the phytobezoar repeatedly using a snare. Small bowel obstructions caused by phytobezoars are often treated with surgical interventions. However, endoscopic fragmentation using a snare is a minimally invasive treatment alternative.

Purpose: To explore the multi-slice spiral computed tomography (MSCT) imaging characteristics of patients with bezoars-induced small bowel obstruction (BI-SBO) to evaluate the risk of conservative treatment., Materials and Methods: This retrospective study included 72 patients with BI-SBO who underwent whole-abdominal MSCT scan within 1 day before treatment. The patients were classified as the non-pass group and pass group depending on whether bezoar can pass after conservative treatment. The CT images were observed and measured by two radiologists. Statistical analysis was performed by using Student's t test, Pearson's chi-squared test, Fisher's exact test, Logistic linear regression, and receiver operating characteristic curve (ROC)., Results: The study population consisted of 72 patients with a mean age of 52.2 ± 16.2 years (32 men and 40 women with an age range of 13-81 years). There were statistical differences between the two groups in the bezoar appearance, maximum HU of bezoar, thickness of intestinal wall, mesenteric haziness, mesenteric fluid, and peritoneal fluid (P = 0.002, 0.024, 0.017, 0.006, 0.021, and 0.030). The appearance of bezoar and mesenteric haziness is independent risk factors affecting whether bezoar can be passed by the conservative treatment. Sensitivity (41.7%) was decreased, NPV (76.3%) was not significantly changed, specificity (93.8%) and PPV (76.9%) were improved when both parameters were met to assess failure of conservative treatment., Conclusion: The observation of important signs by MSCT and its reconstruction technology is of great clinical value in evaluating the passability of bezoar by conservative treatment, and which can provide radiographic basis for clinical treatment selection., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

BACKGROUND Prior studies suggest CT can identify bezoars under certain circumstances. Endoscopy provides diagnostic and therapeutic benefit in the setting of suspected aspirin bezoar. Does the absence of findings on CT scan exclude the presence of an aspirin bezoar? CASE REPORT A 64-year-old woman called the police and stated she ingested a bottle of aspirin to harm herself. Upon arrival to the Emergency Department, she was tachypneic with a GCS of 15. Initial laboratory results were: salicylate level of 1143 mcg/mL, respiratory alkalosis, bicarbonate of 9 meq/L, anion gap of 23, and normal renal function. Initial therapeutic intervention included infusions of glucose and bicarbonate, multiple doses of activated charcoal, intubation, and emergent hemodialysis. After hemodialysis, the salicylate level rebounded, and a Gastroenterology (GI) consultation was requested to rule out bezoar. On day 2, GI requested an abdominal CT scan with Gastrografin in place of endoscopy due to hemodynamic instability. A CT scan was negative for bezoar. After multiple hemodialysis sessions and whole-bowel irrigation with rebounding salicylate levels, GI was consulted again for reevaluation for endoscopy. On day 5, an endoscopy discovered a concretion containing pill fragments. Another endoscopy performed on day 7 removed further fragments. Salicylate levels began to consistently decline. Unfortunately, the patient's neurologic status did not improve, and on day 11 she was switched to palliative care and died. CONCLUSIONS Endoscopy with direct visualization is diagnostic and therapeutic in the setting of a possible bezoar. The absence of pharmacobezoar on imaging should not delay endoscopy in a clinical setting suggesting bezoar.

Enteral feed bezoars are difficult to treat and can lead to serious adverse events. There is no standardized treatment approach and various strategies have been suggested. We herein describe three cases of successful dissolutions of feed bezoars consisting of Promote ® Fibre Plus with sodium bicarbonate 8.4% in critically ill patients. To provide the rationale for this approach, the effect of sodium bicarbonate 8.4% on enteral feed concretions was studied in vitro. First, Promote ® Fibres Plus was incubated with hydrochloric acid with gradually decreasing pH values to establish a pH at which the solution solidifies. The resulting enteral feed concretion was exposed to sodium bicarbonate 8.4% and Coca Cola ® . All patients were successfully treated with sodium bicarbonate 8.4% without the need of lengthy or repeat endoscopies. In vitro, Promote ® Fibres Plus solidifies when acidified below a pH of 4.6. The resulting enteral feed concretions dissolved when exposed to sodium bicarbonate 8.4%. Incubation with Coca Cola ® had no effect. We provide evidence that enteral feed bezoars consisting of Promote ® Fibres Plus can be efficiently and safely treated with sodium bicarbonate 8.4% offering a new approach for daily patient care., (© 2021. The Author(s).)

Introduction: Sixty-three patients with gastric phytobezoars were reviewed., Methods: forty-eight (76.2%) patients received endoscopic combined with chemical therapies and 15 (23.8%) received only chemical therapy initially. Fifty-one (81.0%) patients achieved complete removal (only chemical therapy 14/15), while 12 (19.0%) received further endoscopic therapies., Results: finally, 62 (98.4%) patients achieved a complete removal. Considering only patients with combined treatment as a first approach, treatment success was associated with a softer phytobezoar consistency (p = 0.023)., Conclusion: in conclusion, most patients achieve a favorable outcome. Chemical therapy is useful in selected cases. Repeated endoscopic therapies may be needed in order to completely remove phytobezoars with a hard consistency.

Background: Pharmacobezoars are specific types of bezoars formed when medicines, such as tablets, suspensions, and/or drug delivery systems, aggregate and may cause death by occluding airways with tenacious material or by eluting drugs resulting in toxic or lethal blood concentrations., Objective: This work aims to fully review the state-of-the-art regarding pathophysiology, diagnosis, treatment, and other relevant clinical and forensic features of pharmacobezoars., Results: Patients of a wide range of ages and of both sexes present with signs and symptoms of intoxications or more commonly gastrointestinal obstructions. The exact mechanisms of pharmacobezoar formation are unknown but are likely multifactorial. The diagnosis and treatment depend on the gastrointestinal segment affected and should be personalized to the medication and the underlying factor. A good and complete history, physical examination, image tests, upper endoscopy, and surgery through laparotomy of the lower tract are useful for diagnosis and treatment., Conclusion: Pharmacobezoars are rarely seen in clinical and forensic practice. They are related to controlled or immediate-release formulations, liquid, or non-digestible substances, in normal or altered digestive motility/anatomy tract, and in overdoses or therapeutic doses, and should be suspected in the presence of risk factors or patients taking drugs which may form pharmacobezoars., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

BACKGROUND Indigestible foreign material in the bowel can develop into bezoars. Intestinal obstruction can occur secondary to these bezoars. Phytobezoars specifically refer to those which accumulate as a result of undigested plant or other food material. CASE REPORT A 42-year-old woman presented to the Emergency Department with a several-month history of right-sided abdominal pain associated with bouts of vomiting. She had no other significant medical history. Labs and computed tomography were unrevealing. Gastroenterology was consulted and performed endoscopy. A foreign body resembling an undigested mini bell pepper was found near the terminal ileum. This was removed, and the patient later reported significant improvement in her symptoms. CONCLUSIONS Phytobezoars can lead to symptoms consistent with intestinal obstruction. The underlying pathology (e.g., masses, gastritis, adhesions, or dysmotility) can precipitate obstructions in the setting of bezoar formation. Surgical removal if often necessary for small-bowel obstructions secondary to bezoars, but in our case, fortunately, the foreign body was successfully removed during endoscopy.

Phytobezoars are rare causes for intestinal obstruction. Therapy options include surgical removal, enzyme treatment, endoscopic removal and lyis with Coca-Cola ® . While there is ample literature about successful Coca-Cola ® -lysis, little is to be found concerning intestinal beozars. In our case, neither surgical nor endoscopic treatment of the intestinal obstruction was possible, which is why we opted for a Coca-Cola ® -lysis., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: None

Clinical Presentation: An elderly female patient was admitted to intensive care for prolonged vasopressor therapy and mechanical ventilation after cardiac arrest and acute percutaneous coronary intervention. Antiplatelet, thyroid hormone replacement and statin therapies were administered through a 14-French nasogastric tube (Nestlé Health Science) and enteral feeding was initiated. Correct position of the nasogastric tube was confirmed radiologically. On the seventh day in the intensive care, our patient was seen to regurgitate soft crumbs into her mouth. The blocked nasogastric tube was removed, but attempts to reinsert another tube failed.Upper GI endoscopy revealed an obstruction of the oesophagus with a milky-yellowish caseous substance 20 cm from the incisors (figure 1). The proximal part of the mass showed a central hole and ring-shaped layers resembling the cut face of a tree trunk.gutjnl;68/2/206/F1F1F1Figure 1Obstruction of the oesophagus with a milky-yellowish caseous substance., Questions: What caused the obstruction?How should we manage such a problem?, Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Seed bezoars are a subcategory of phytobezoars, caused by consumption of indigestible vegetable or fruit seeds. We present the case of a 64-year-old male patient, who presented at the Emergency Department, complaining of constipation, tenesmus and rectal pain. History and digital examination revealed a rectal seed bezoar due to sunflower seeds, impacted in the lower rectum. The patient underwent manual disimpaction under general anaesthesia, after conservative measures failed. Seed bezoars represent a different pathophysiological process compared to fibre bezoars. They are usually found in the rectum of patients without predisposing factors, causing constipation and anorectal pain. History taking and digital rectal examination are the cornerstones of diagnosis, with manual disimpaction under general anaesthesia being the procedure of choice., Competing Interests: The authors declare no competing interests.

Rationale: Intragastric bezoar is a stony mass found trapped in the stomach, though it can occur in other locations of the gastro-intestinal tract. The etiology of intragastric bezoar is multifactorial, includes certain risk factors and predisposing factors such as coexisting medical disorders, anatomic abnormalities, and gastric motility disorders, which contribute to the development of intragastric bezoar., Patient Concerns: In this report, we present a rare case of intragastric bezoar with epigastric pain after prolonged consumption of jujubes. To our knowledge, this is the first case of intragastric bezoar to be reported after jujubes ingestion., Diagnoses: An upper gastrointestinal (GI) endoscopy performed which revealed an 8 × 5-cm intragastric diospyrobezoar with an adjacent necrotic pressure ulcer of size 0.8 × 0.5-cm without signs of bleeding., Interventions: For therapeutic intervention, Coca-Cola ingestion and lithotripsy were applied., Outcomes: The therapeutic course was uneventful. There was no recurrence during 1-year follow-up., Lessons: In our literature, jujube emerged as a new player. A bezoar composed of unripened fruit content in the stomach, could be the cause of chronic abdominal pain, dyspepsia, gastric reflux or heartburn. Moreover, this study provides a detailed overview of recently published literature regarding intragastric manifestations of bezoar, etiological factors, diagnostic and therapeutic approaches.

Background: Renal fungal bezoars are remarkably rare and mostly occur in immunodeficient patients. Only a small number of cases with immunocompetent patients have been published so far. The published treatment approaches comprised systemic antimycotic therapy and surgical or minimal invasive removal of the fungal balls. In some cases irrigation of the renal duct system with amphotericin B was performed. By obstruction of the urinary tract bezoars can lead to infected hydronephrosis and severe urosepsis with high lethality. Fungaemia can cause fungal colonization in different distant organs. Fulminant chorioretinitis and irreversible visual impairment can be the consequence of ocular fundus colonization. The following report highlights that a co-operation between urologists and ophthalmologists is absolutely indispensible in case of fungaemia., Case Presentation: Hereinafter we describe a case of an immunocompetent 56 years old woman, presenting with flank pain and shivering. The diagnosis turned out to be difficult due to initially negative urine culture. The fungaemia caused by obstructive nephropathy led to bilateral candida chorioretinitis. The patient was treated with intravenous amphotericin b and the bezoar was removed by percutaneous "nephrolitholapaxy". After two months, a follow up revealed the patient felt well, chorioretinal lesions regressed and urine culture did not show any fungal growth., Conclusion: To the best of our knowledge, this is the first case reporting on obstructive renal bezoars, which lead to haematogenous fungus spread and bilateral chorioretinitis. It points out that extensive ophthalmologic examination should be performed in case of fungaemia even if the patient is not suffering from any visual impairment.

Resumen: Introduction: Trichobezoars are an intraluminal accumulation of ingested hair. The Rapunzel syndrome refers to the presence of gastric trichobezoars which extend to the small intestine together with trichotillomania and trichophagia, that occur predominantly in psychiatric patients of pediatric age., Objective: To analyze the clinical course and resolution of this syndrome in a case report. Likewise, we provide information about the family environment and psycho-emotional context of the patients and help the reader identify similar circumstances in their clinical practice., Case Report: Female 14-year-old patient with history of trichotillomania and trichophagia of two years of evolution, who consulted for epigastric pain associated with weight loss, nausea, and postprandial fullness. During the physical examination, the patient was found to have bald patches in the scalp along with a palpable mass that seemed to be confined to the gastric limits. Imaging studies revealed gastric occupation due to a bezoar formation. The patient was treated surgically with laparotomy and gastrostomy, and two simultaneous trichobezoars were removed from the patient´s stomach and duodenum, the patient also underwent psycho-emotional professional counseling., Conclusion: Rapunzel´s syndrome, far for being a merely surgical entity, also requires psychoemotional assessment to prevent it recurrence and limit its severity.

An 82-year-old Japanese man visited our hospital with abdominal fullness accompanied by lower abdominal pain. He presented with small bowel obstruction due to multiple diospyrobezoars. The bezoars were successfully removed without any surgical intervention by the administration of Coca-Cola Zero through a long intestinal tube and subsequent endoscopic manipulation. Such a combination may be the treatment of choice for small bowel obstruction due to bezoars.

A 67-year-old man suffering from epigastric pain showed a phytobezoar in the endoscopy. Therapy with Coca Cola® and enzymes was initiated. The (partial) lysis led to a migration of the bezoar into the ileum, resulting in a small bowel obstruction. After removal of the remaining bezoar via ileotomy a secondary pneumatosis intestinalis occurred. As a rare finding the (phyto-)bezoar should be considered as a differential diagnosis of abdominal pain - especially considering the rising numbers of bariatric surgery, which is a potential risk factor. Furthermore, intestinal obstruction after migration has to be considered as a relevant complication of treatment.

Trichotillomania can be associated with the formation of trichobezoars (hair ball) usually located in the stomach. Trichobezoars may lead to complications including bowel obstruction, and perforation. Patients with a history of diabetes, certain psychiatric disorders, prior gastric surgery and poor mastication ability are at an increased risk of developing bezoars. We are presenting a case of patient who suffered from a large, recurrent trichobezoar, who had a history of gastric bypass surgery as well as trichotillophagia. The endoscopic method used to remove the large bezoar will also be discussed. We have reviewed the cases published, in which patients developed bezoars after undergoing gastric bypass surgery. The purpose of this study is to raise awareness among clinicians that patients with certain psychiatric issues who had prior gastric surgeries, are at eminent risk of bezoar formation. A multidisciplinary approach including cognitive behavioural therapy, dietary education and pharmacotherapy should be taken to prevent complications., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Esophageal obstruction from soluble fiber laxatives, such as karaya gum, has been rarely reported in the literature. However, as such preparations are widely commercially available, it is important for gastroenterologists to be aware of their potential to form a bezoar in the esophagus due to swelling on contact with liquid. This report highlights such a case and discusses its challenging management.

A 13-year-old female was presented to the emergency department following an intentional ingestion. The patient developed significant toxicity including multiple, discreet tonic-clonic seizures. Despite appropriate resuscitation and antidotal management, the patient's symptoms persisted for more than 36 hours post-ingestion. An upright abdominal radiograph was performed revealing a radiopacity suggesting a pharmacobezoar. An esophagogastroduodenoscopy was performed with successful removal of a tennis ball-sized pharmacobezoar. The patient's symptoms subsequently subsided and she recovered fully with no neurologic deficits. Diphenhydramine has not been previously identified as a medication likely to form a pharmacobezoar and has not been shown to be radiopaque. Though bezoar formation is a rare clinical scenario, it is one that toxicologists must consider in patients with clinical courses that persist far beyond expected based on known toxicokinetic principles.

Bezoars are collections of undigested foreign material that accumulate in the gastrointestinal tract. The most common are phytobezoars, which are formed from plant fibers, especially those related to the ingestion of persimmon. Patients who undergo abdominal surgery, including bariatric surgery for obesity, and particularly gastrectomy, are prone to bezoar formation due to reduced gastric motility, loss of pyloric function, and hypoacidity. Bezoars can form months to years postoperatively. Our objective was to review the published literature regarding phytobezoar formation after bariatric surgery. We investigated the entire scientific literature on phytobezoars as a complication after bariatric surgery using PubMed and Embase searches of all reports published to date. We used the following keywords: "phytobezoars" or "bezoars" and "bariatric surgery" or "laparoscopic adjustable gastric band" or "laparoscopic sleeve gastrectomy" or "Roux-en-Y gastric bypass" or "single anastomosis gastric bypass" or "biliopancreatic diversion." Seventeen eligible articles were included in the study. We provide an overview of the incidence, classification, and manifestations of bezoar formation as a rare, late morbidity of bariatric surgery. Treatment options include chemical enzyme therapy, endoscopic dissolution and removal, or surgery. Nutritional counseling regarding bezoar formation and prevention of recurrence after bariatric surgery should emphasize changing eating habits, including sufficient drinking and chewing and avoiding the overindulgence of foods with high-fiber content, especially citrus pith and persimmons. Clinicians should be aware of this potential rare complication. Additional studies are needed to examine the eating habits and food choices of bariatric patients with bezoar complications and to elucidate more clearly the risk factors for this pathologic condition., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Primary renal aspergillosis, though a rare entity, is still seen in immune compromised individuals. Renal aspergillosis may lead to formation of focal abscesses, fungal bezoars and may cause ureteric obstruction. Treatment involves stabilization of patient and removal of fungal bezoars along with administration of anti-fungal agents. This report describes the case of localized primary renal aspergillosis with fungal bezoars formation in a 55 years old female, diabetic, hypertensive, who presented with upper urinary tract obstruction and was successfully managed by endoscopic removal of fungal bezoars and intravenous amphotericin followed by oral itraconazole.

Background: Pills in sharp packaging that are accidentally swallowed (blisters) can cause perforations in the gastrointestinal tract, which are only clinically apparent after the emergence of mediastinitis or peritonitis. Mortality is high., Patients: We have seen two cases in cognitively limited patients, one with oesophageal and one with ileal perforation., Results: Despite surgery, the patient with oesophageal perforation died 3 weeks later of multi-organ failure. The patient with ileal perforation survived sepsis after multiple procedures., Conclusion: As a consequence, a hospital-wide policy was implemented prohibiting the issue of tablets in blister packaging at the bedside. No more cases have emerged since that time., (Georg Thieme Verlag KG Stuttgart · New York.)

To investigate the mechanism of phytobezoar dissolution by Coca-Cola(®), persimmon phytobezoar pieces removed from a 60-year-old Japanese woman were analyzed by energy dispersive X-ray spectroscopy. The amount of calcium significantly decreased after dissolution treatment using Coca-Cola(®), suggesting a potential contribution of calcium to dissolution mechanisms. Moreover, immersion in Coca-Cola(®) for 120 hours on the exterior surface revealed that Coca-Cola(®) did not permeate persimmon phytobezoars. This is the first study to investigate the mechanisms of persimmon phytobezoar permeability and dissolution induced by Coca-Cola(®).

Gastric bezoars are concretions of undigested material, and Coca-Cola therapy is an easy, efficacious and safe approach for bezoar treatment. Gastric outlet obstruction due to a migratory gastric bezoar during Coca-Cola therapy is an uncommon presentation and, to the best of our knowledge, no cases have been previously reported. We herein describe one such case with no known predisposing factors that recovered via the endoscopic technique. A thorough literature search was performed, which yielded eight relevant patients from seven publications, all of who developed gastrointestinal obstruction during dissolution treatment and recovered uneventfully after surgical intervention. In conclusion, this potential complication should be kept in mind in the event that alternative treatment is necessary.

Background: Although bezoar dissolution by Coca-Cola® has been described in case reports and case series, to the best of our knowledge, the usefulness of other cola products such as Pepsi-Cola® has never been reported in the English literature., Case Report: An 86-year-old Taiwanese man was diagnosed with a gastric bezoar. Endoscopic fragmentation with a polypectomy snare was attempted twice but failed to remove the bezoar. Subsequently, 500 mL of Pepsi NEX Zero® was administered daily for 4 days via nasogastric tube. The bezoar was softened and successfully fragmented by the polypectomy snare and needle-knife devices on the third attempt., Conclusions: This report presents the first case of a gastric bezoar successfully treated by endoscopic fragmentation in combination with Pepsi-Cola® administration, suggesting the possible utility of cola beverages in bezoar treatment, regardless of product brands.

Introduction: Candida bezoar (CB) is a rare finding in neonates and infants with candiduria, presenting as necrotic debris with proliferating mycelia in the collecting system of the kidney. If initial antifungal medical treatment does not result in clearance of candiduria and disappearance of CB on ultrasound in dilated kidneys, invasive interventions like insertion of nephrostomy tubes (NT) or surgical interventions to drain the kidney are sometimes advocated(.). However, NT placement can be a technical challenge, especially in pre- and dysmature neonates, and NT displacement or obstruction by the CB can lead to suboptimal treatment. Identification of those children who will benefit from invasive renal drainage is important., Objective: This study evaluates the management of patients with CB in three tertiary referral hospitals to determine criteria for intervention., Materials and Methods: A retrospective multicenter chart analysis was conducted of children with candiduria and ultrasonographic demonstration of CB (diagnosed between March 1995 and August 2012). The indication for invasive renal drainage (if performed) and subsequent clinical outcome, serum creatinine levels and ultrasound findings were assessed., Results: A total of 12 children were included, two of which were premature neonates. Eight children had congenital urogenital anomalies. One older child with acute myeloid leukemia had CB during chemotherapy and one ex-premature developed CB following cerebral candidiasis. All children received systemic antifungal medication; in seven children invasive treatment was added. Indications for invasive treatment were clinical deterioration, progressive renal dilation, pyonephrosis, rising creatinine levels and persistence of CB. Two underwent a Y-cutaneous ureterostomy and nephrostomy tubes were inserted in five children. Percutaneous renal drainage by nephrostomy led to complications in 3 of 6 procedures. In all patients, irrespective of therapeutic modality, follow-up ultrasound demonstrated no de novo changes. No additional parenchymal defects or deterioration of split renal function were seen on DMSA or MAG-3 scan., Discussion: In the literature renal drainage is suggested in case of complete obstruction. However dilatation is a frequent finding in children as part of the congenital renal anomaly and does not necessarily mean that there is obstruction of the urinary tract. Even in children without candida infections the diagnosis of obstruction is not straightforward, while the results of a MAG 3 scan can be obscured by compromised kidney function, parenchymal bacterial infiltration and neonatal immaturity of the kidney. If candiduria and CB persist despite intensive medical treatment, intensive consultation is required before renal drainage, because NT insertion might be a surgical challenge. Complications such as displacement of the NT, urinoma development, or NT obstruction can occur and was seen in three of six procedures. Premature neonates seem to be more prone to complications due to their small anatomical proportions, requiring medical equipment with small diameters prone to displacement and obstruction. Some studies describe successful pharmaceutical management in the majority of patients with CB. Other studies describe unilateral surgical intervention in children with bilateral CB where unilateral drainage did not influence overall renal outcome. This is in line with our results. A limitation of the present study is its retrospective design. In this population, the motivation for invasive renal drainage or conservative management was not well documented in all cases, and was mainly based on clinical and diagnostic parameters like creatinine levels and radiographic findings., Conclusion: Renal drainage should be considered in selected cases after failure of systemic antifungal treatment. Inserting and maintaining a nephrostomy tube in young children is associated with a high rate of complications; conservative treatment is likely to be sufficient in the majority of patients with candiduria and CB., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Bezoars represent the most frequent foreign bodies of gastro-intestinal system, involving first of all the stomach and small intestine; instead the cecum tract is a very uncommon site for bezoars associated with a poor abdominal symptomatology. We report a case of a very rare localization of bezoar in the caecum tract of the ascending colon in a child affected by undefined abdominal pain. In this case, the abdominal Ultrasound examination showed characteristic imaging findings of bezoar completely comparable to that of Computed Tomography, allowing an early diagnosis of bezoar and the possibility of a conservative treatment for the young patient.

Gastroparesis is a chronic disorder of abnormal gastric motility causing considerable suffering. We describe two cases of gastroparesis which were treated by methods which were not part of routine conventional therapy, but which, nevertheless, led to significant clinical improvement. In the first case, the patient suffered from gastroparesis following a vagal injury while undergoing a lung transplant. During his illness a mega-bezoar formed, a well-described complication of gastroparesis. After conservative measures failed, and in order to avoid a surgical intervention that carried considerable risk under the circumstances, a successful trial consisting of imbibing large amounts of "Coca Cola" and acupuncture was initiated. The bezoar dissolved completely and considerable improvement of the patient's gastric motility was achieved. In the second case, the patient was a young woman suffering from idiopathic gastroparesis, which responded well to treatment with tricyclic antidepressants. Due to her intention to become pregnant, this treatment was discontinued and she was admitted to receive homeopathic treatment. After two failed attempts in finding the right homeopathic remedy to replace the conventional treatment, the third remedy (Sepia) used brought dramatic improvement in her general condition and her dyspepsia. Today, over two years after her successful homeopathic treatment, she is in the middle of her second pregnancy, without any treatment and free of complaints. These two cases are examples of simple solutions for seemingly complicated and complex conditions alleviated by an integration of conventional and complementary/alternative medicine.

Background and Study Aims: Bezoars result from accumulation of indigestible materials in the gastrointestinal tract and often occur in the stomach. In this study, we evaluated the use of guidewires in patients with gastric phytobezoars (PBs) as a new method for PB removal and examined the safety of the procedure., Patients and Methods: Between February 2009 and January 2013, we analyzed data from 11 patients with gastric PBs. We fitted a transparent cap to a standard endoscope (EG450WR5, Fujinon), and a 0.025 inch guidewire was passed through the standart endoscope. PBs were surrounded by a loop in the guidewire and destroyed. After 2 weeks of treatment, patients were re-evaluated for effectiveness., Results: PB fragmentation time was 5-11 minutes. In five patients with a history of gastric surgery, we needed an additional 16-28 minutes for removal of the fragments. In six patients additionally treated with enzymatic degradation after the breaking procedure, PBs completely disappeared within 2 weeks. There were no complications during the procedure., Conclusions: The guidewire and fragmentation procedure for PBs is an efficient and reliable method. When combined with enzymatic degradation, PBs can be managed quickly and effectively.