Bezoar

Bezoar stones were seen as valuable commodities, sometimes with magical healing properties, as in the early modern English case Chandelor v Lopus^[1]

Bezoar
Classification and external resources
Specialty	emergency medicine
ICD-10	T18
ICD-9-CM	938
DiseasesDB	30758
MedlinePlus	001582
MeSH	D001630

A bezoar /ˈbiːzɔər/ is a mass found trapped in the gastrointestinal system (Gastrolith, usually in the stomach),^[2] though it can occur in other locations.^[3][4] A pseudobezoar is an indigestible object introduced intentionally into the digestive system.^[5]

There are several varieties of bezoar, some of which have inorganic constituents and others organic. The term has both a modern (medical, scientific) and a traditional usage.

History

Bezoars were sought because they were believed to have the power of a universal antidote against any poison. It was believed that a drinking glass which contained a bezoar would neutralize any poison poured into it. The word "bezoar" comes from the Persian pād-zahr (پادزهر), which literally means "antidote".

The Andalusian physician Ibn Zuhr (d. 1161), known in the West as Avenzoar, is thought to have made the earliest description of bezoar stones as medicinal items.^[6] Extensive reference to it is also to be found in the Picatrix, which may be earlier.

In 1575, the surgeon Ambroise Paré described an experiment to test the properties of the bezoar stone. At the time, the bezoar stone was deemed to be able to cure the effects of any poison, but Paré believed this was impossible. It happened that a cook at King's court was caught stealing fine silver cutlery and was sentenced to death by hanging. The cook agreed to be poisoned instead. Ambroise Paré then used the bezoar stone to no great avail, as the cook died in agony seven hours later.^[7] Paré had proved that the bezoar stone could not cure all poisons as was commonly believed at the time.

Modern examinations of the properties of bezoars by Gustaf Arrhenius and Andrew A. Benson of the Scripps Institution of Oceanography have shown that they could, when immersed in an arsenic-laced solution, remove the poison. The toxic compounds in arsenic are arsenate and arsenite. Each is acted upon differently, but effectively, by bezoar stones. Arsenate is removed by being exchanged for phosphate in the mineral brushite, a crystalline structure found in the stones. Arsenite is found to bond to sulfur compounds in the protein of degraded hair, which is a key component in bezoars.^[8]

A famous case in the common law of England (Chandelor v Lopus, 79 Eng Rep. 3, Cro. Jac. 4, Eng. Ct. Exch. 1603) announced the rule of caveat emptor, "let the buyer beware", if the goods they purchased are not in fact genuine and effective. The case concerned a purchaser who sued for the return of the purchase price of an allegedly fraudulent bezoar. (How the plaintiff discovered the bezoar did not work is not discussed in the report.)

The Merck Manual of Diagnosis and Therapy notes that consumption of unripened persimmons has been identified as causing epidemics of intestinal bezoars, and that up to 90% of bezoars that occur from eating too much of the fruit require surgery for removal.^[9]

A 2013 review of three databases identified 24 publications presenting 46 patients treated with Coca-Cola for phytobezoars. The cola was administered in doses of 500 mL to up to 3000 mL over 24 hours, orally or by gastric lavage. A total of 91.3% of patients had complete resolution after treatment with Coca-Cola: 50% after a single treatment, others requiring the cola plus endoscopic removal. Surgical removal was resorted to in four patients. ^[10]

Types by content

• Food boluses (or boli; singular bolus) carry the archaic and positive meaning of bezoar, and are composed of loose aggregates of food items such as seeds, fruit pith, or pits, as well as other types of items such as shellac, bubble gum, soil, and concretions of some medications.
• Lactobezoar is a specific type of food bezoar comprising inspissated milk. It is most commonly seen in premature infants receiving formula foods.
• Pharmacobezoars (or medication bezoars) are mostly tablets or semiliquid masses of drugs, normally found following overdose of sustained-release medications.^[11]
• Phytobezoars are composed of indigestible plant material (e.g., cellulose), and are frequently reported in patients with impaired digestion and decreased gastric motility.
• Diospyrobezoar is type of phytobezoar formed from unripe persimmons.^[12] Coca-Cola has been used in the treatment.^[13][14][15]
• Trichobezoar is a bezoar formed from hair^[16] – an extreme form of hairball. Humans who frequently consume hair sometimes require these to be removed. The Rapunzel syndrome, a very rare and extreme case, may require surgery.

Types by location

• A bezoar in the esophagus is common in young children and in horses. In horses, it is known as choke.
• A bezoar in the large intestine is known as a fecalith.
• A bezoar in the trachea is called a tracheobezoar.

Production and uses of bezoars

• Esophageal bezoars in the nasogastrically fed patients on mechanical ventilation and sedation have been reported to be due to precipitation of certain food types rich in casein, which get precipitated with gastric acid reflux to form esophageal bezoars.
• Ox bezoars (cow bezoars) are used in Chinese herbology, where they are called niu-huang (牛黃) or calculus bovis. These are gallstones, or substitutes, from ox or cattle gall bladder bile. There are artificial calculus bovis used as substitutes. These are manufactured from cholic acid derived from bovine bile.^[17] In some products, they claim to remove "toxins" from the body.
• In alchemy, "animal bezoar" is the heart and lungs of the viper, pulverized together.^[18] Mineral bezoar is an emetic powder of antimony, correct with nitric acid, and softened by repeated lotions, which were said to carry off the purgative virtue of the antimony, and substitute a diaphoretic one. It promoted sweat like the stone of the same name.^[18]

See also

• Bezoardicum
• Enterolith
• Gorochana
• Regurgitalith
• Snake-stones
• Toadstone
• List of English words of Persian origin
• Coca-Cola treatment of phytobezoars

References

Notes

1. (1603) 79 ER 3
2. "bezoar" at Dorland's Medical Dictionary
3. Bala M, Appelbaum L, Almogy G (November 2008). "Unexpected cause of large bowel obstruction: colonic bezoar". Isr. Med. Assoc. J. 10 (11): 829–30. PMID 19070299.
4. Pitiakoudis M, Tsaroucha A, Mimidis K; et al. (June 2003). "Esophageal and small bowel obstruction by occupational bezoar: report of a case". BMC Gastroenterol 3 (1): 13. doi:10.1186/1471-230X-3-13. PMC 165420. PMID 12795814.
5. Mintchev MP, Deneva MG, Aminkov BI, Fattouche M, Yadid-Pecht O, Bray RC (1 February 2010). "Pilot study of temporary controllable gastric pseudobezoars for dynamic non-invasive gastric volume reduction". Physiol. Meas. 31 (2): 131–44. doi:10.1088/0967-3334/31/2/001. PMID 20009188.
6. Byrne, Joseph P. Encyclopedia of the Black Death. ABC-CLIO. p. 33. ISBN 1598842536.
7. Stephen Paget (1897). Ambroise Paré and His Times, 1510–1590. G.P. Putnam's Sons. pp. 186–187.
8. http://www.melfisher.org/bezoar.htm [dead link]
9. Merck Manual, Rahway, New Jersey, Sixteenth Edition, Gastrointestinal Disorders, Section 52, p. 780
10. Ladas SD, Kamberoglou D, Karamanolis G, Vlachogiannakos J, Zouboulis-Vafiadis I (2013). "Systematic review: Coca-Cola can effectively dissolve gastric phytobezoars as a first-line treatment". Aliment Pharmacol Ther 37 (2): 169–173. doi:10.1111/apt.12141. PMID 23252775.
11. Buckley NA, Dawson AH, Reith DA (January 1995). "Controlled release drugs in overdose. Clinical considerations". Drug Safety: an International Journal of Medical Toxicology and Drug Experience 12 (1): 73–84. doi:10.2165/00002018-199512010-00006. PMID 7741985.
12. Kishan, Asn; Kadli, NK (2001). "Bezoars". Bombay Hospital Journal.
13. Chung YW, Han DS, Park YK; et al. (July 2006). "Huge gastric diospyrobezoars successfully treated by oral intake and endoscopic injection of Coca-Cola". Dig Liver Dis 38 (7): 515–7. doi:10.1016/j.dld.2005.10.024. PMID 16330268.
14. Ha SS, Lee HS, Jung MK; et al. (December 2007). "Acute Intestinal Obstruction Caused by a Persimmon Phytobezoar after Dissolution Therapy with Coca-Cola". The Korean journal of internal medicine 22 (4): 300–3. doi:10.3904/kjim.2007.22.4.300. PMC 2687663. PMID 18309693.
15. Hayashi, Kazuki; Ohara, Hirotaka; Naitoh, Itaru; Okumura, Fumihiro; Andoh, Tomoaki; Itoh, Takafumi; Nakazawa, Takahiro; Joh, Takashi (November 12, 2008). "Persimmon bezoar successfully treated by oral intake of Coca-Cola: a case report". Cases Journal (London, England, U.K.: BioMed Central, published December 11, 2008) 1: 385. doi:10.1186/1757-1626-1-385. ISSN 1757-1626. OCLC 234326274. Retrieved November 23, 2015. Referring to past reports [1-9], the period from the administration of Coca-Cola until the disappearance of the bezoars was a minimum of 1 day and a maximum of 2 months.
16. Malhotra A, Jones L, Drugas G (November 2008). "Simultaneous gastric and small intestinal trichobezoars". Pediatr Emerg Care 24 (11): 774–6. doi:10.1097/PEC.0b013e31818c2891. PMID 19018222.
17. Ingredients, AN KUNG NIU HUANG WAN (Bezoar Chest Functioning Pills), Peking Tung Jen Tang, Peking, China. 1980.
18. Chambers, Ephraim (1728). "Bezoar". Cyclopaedia, or an Universal Dictionary of Arts and Sciences 1. London. p. 98b.

Bibliography

• Barry Levine. 1999. Principles of Forensic Toxicology. Amer. Assoc. for Clinical Chemistry. ISBN 1-890883-87-5.
• Martín-Gil FJ, Blanco-Ávarez JI, Barrio-Arredondo MT, Ramos-Sanchez MC, Martin-Gil J. Jejunal bezoar caused by a piece of apple peel – Presse Med, 1995 Feb. 11; 24(6):326.
• The Poison Sleuths: Arsenic – The King of Poisons. Retrieved March 10, 2007. (This webpage is a reprint by the author of an article originally published in the 1997 issue of Science Reporter, published by the National Institute of Science Communication (CSIR) in India.)
• This article incorporates text from a publication now in the public domain: Chambers, Ephraim (ed.). "Bezoar". Cyclopædia, or an Universal Dictionary of Arts and Sciences. James and John Knapton, et al.

Further reading

• Borschberg, Peter, "The Euro-Asian Trade in Bezoar Stones (approx. 1500–1700)", Artistic and Cultural Exchanges between Europe and Asia, 1400–1900: Rethinking Markets, Workshops and Collections, ed. Thomas DaCosta Kaufmann and Michael North, Aldershot: Ashgate, 2010, pp. 29–43. https://www.academia.edu/4311591
• Borschberg, Peter, "The Trade, Forgery and Medicinal Use of Porcupine Bezoars in the Early Modern Period (c.1500–1750)", ed. Carla Alferes Pinto, Oriente, vol. 14, Lisbon: Fundação Oriente, 2006.

External links

• A trichobezoar at the National Museum of Health and Medicine, Washington DC.
• Bezoars, Phytobezoars and Diospyrobezoars
• A trichobezoar from MedPix
• CT images of bezoar from MyPACS.net