Cellulase bezoar injection: a new endoscopic technique M. H. Gold, Jr, MD Thomas E. Patteson, III, MD Gerald I. Green, MD Camp Lejeune, North Carolina
Two cases of phytobezoar dissolution employing direct endoscopic injection of cellulase (Gastroenterase) after failure of previously described nonsurgical techniques are presented. This method of therapy may eliminate the need for hospitalization and may decrease both morbidity and prolonged patient discomfort. Since the advent of surgery in the management of peptic ulcer disease, the problem of gastric bezoar has become increasingly more prevalent. Until recently, the only available treatment was surgical intervention. The purpose of this report is to introduce a new and direct endoscopic technique for treating gastric phytobezoars. The following cases illustrate this simple method for bezoar dissolution which is heretofore undescribed in the literature. REPORTS OF CASES 1. A 47-year-old woman was referred to the Naval Regional Medical Center Hospital, Camp Lejeune, NC, in June 1974 for evaluation of abdominal pain. In August 1972 the patient had undergone an exploratory laparotomy with vagotomy and pyloroplasty for hemorrhage from a gastric ulcer in the proximal stomach. She did well until March 1974 when she noted the onset of epigastric and left upper quadrant cramping pain which began 15 to 20 minutes postprandially and persisted for 1 to 3 hours. The pain was always associated with ingestion of solid foods but not with liquids. The patient also noted early satiety and nausea without vomiting. During the 6 months before evaluation she had lost approximately 20 pounds. Physical examination was unremarkable. An upper gastrointestinal study revealed the presence of an irregular mass within the antrum, body, and fundus of the stomach which was fixed to the posterior wall (Figure 1A). In addition, a contraction ring was noted in the antrum, making identification of the true pylorus difficult. Subsequent gastroscopy revealed a 7 cm x 9 cm, green, gelatinous, adherent mass
on the posterior wall of the body and fundus of the stomach. Mechanical disruption with biopsy forceps was performed revealing an inflamed mucosa beneath the bezoar. The previously noted antral deformity was seen as a circumferential mucosal indentation appearing as a pseudopylorus through which peristalsis progressed poorly. The distal antrum, pylorus, and duodenum were normal and consistent with a surgical pyloroplasty with proximal antral surgical deformity. The patient was instructed to ingest commercial meat tenderizer (Adolph's), one-halfteaspoonful in applesauce 3 times daily. When reevaluated several weeks later, symptoms were unchanged. Repeated upper gastrointestinal radiography revealed persistence of the gastric bezoar, although smaller in size. We next attempted to dissolve the bezoar utilizing oral cellu lase. Th ree tablets of Gastroenterase (Wampole Laboratories, Stamford, Ct.), were crushed and swallowed with a glass of water after each meal for a period of 3 days. Her symptoms remained unchanged, and repeated gastroscopy on 25 September revealed the phytobezoar, unchanged in size or position. A second trial of Gastroenterase was made at the same dosage but extended to 7 day5, again without symptomatic improvement. In late November 1974, 6 Gastroenterase tablets were crushed and suspended in 300 ml of warm water. This solution was then injected directly into the body of the bezoar through a polyethylene catheter inserted through the biopsy channel of the gastroscope. Upper gastrointestinal radiographs taken 2 weeks later revealed no evidence of the bezoar (Figure 1B). Because of persistent symptoms, elective
From the Department of Internal Medicine, Naval Regional Medical Center, Camp Lejeune, North Carolina. The opinions expressed herein are those of the authors and cannot be construed as reflecting the views of the Navy Department or of the Naval Service at large. Reprint requests: M. H. Gold, MD, Department of Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23219.
200
GASTROINTESTINAL ENDOSCOPY
Figure 1. A, An irregular mass occupies the antrum, body, and fundus of the stomach. B, The fill ing defect is no longer apparenl 2 weeks after the bezoar was injecled with Gaslroenterase.
laparotomy was performed in January 1975. An anterior gastrotomy was made 5 cm from the esophagogastric junction, and thorough inspection of the stomach revealed no evidence of residual bezoar. A moderate stenosis of the antrum proximal to the pyloroplasty was noted. This was opened along the previous suture line, a web of mucosa extending from anterior to posterior at the level of the stenosis was taken down, and the pyloroplasty was reconstructed as a long Heineke-Mikulicl. procedure. The patient has been asymptomatic during the 4 months since discharge. 2. A 69-year-old woman presented to the Naval Regional Medical Center emergency room on 24 August 1974 complaining of sharp, intermittent, epigastric pain for 3 days. The pain was worsened by food, relieved by emesis, and unaffected by alkali ingestion. Her medical history included a cholecystectomy, mild essential hypertension, chronic obstructive pulmonary disease, and moderately severe depression with anxiety neurosis. In the early 1950's, she began a long course of medical therapy for an antral ulcer. In July 1970, she underwent laparotomy for a persistent antral defect seen on upper gastrointestinal series. At operation, a small hiatus hernia and a scarred proximal duodenum and antrum were found. A bilateral vagotomy, hemigastrectomy, and Billroth I anastomosis were performed. She experienced no further gastrointestinal symptoms until August 1974. Physical examination revealed findings consistent with chronic obstructive pu Imonary disease and was otherwise unremarkable. Upper gastrointestinal rad iography on 27 August revealed a nonhomogeneous, irregular mass filling the entire gastric remnant. In addition, a large amount of retained secretions was present in the stomach (Figure 2A). Gastroscopy was performed on 10 September, revealing an 8 cm x 10 cm gelatinous mass fixed to the gastric wall and extending from
the proximal body of the stomach to just proximal to the anastomosis (Figure 3.). Attempts to mechanically disrupt the mass with both the endoscope and the biopsy forceps were only partially successful. Shortly after the procedure the patient regurgitated several fragments of a green, gelatinous mass containing portions of undigested celery and onion skin. Repeated upper gastrointestinal radiography 8 days postgastroscopy showed numerous irregular filling defects in the gastric remnant consistent with residual bezoar. Because of persistent, although diminished symptoms, the patient was given a trial of Gastroenterase (3 pu Iverized tablets swallowed with water after each of 3 meals daily for 3 days). Gastroscopy
Figure 3. Gastroscopic view showing a heaped-up gelatinous bezoar (b) fixed to lhe gastric folds (f). The angularis (a) is seen in the upper
right of the photograph.
Figure 2. A, An inhomogeneous mass fills the gastric remnant. B, A normal remnant and gastroduodenostomy is seen 10 days after instillalion of Gastroenterase into the bezoar. VOLUME 22, NO.4, 1976
201
2 weeks later revealed persistence of the gastric bezoar which was again resistent to endoscopic disruption. A second trial of Gastroenterase was conducted, increasing the treatment period to 6 days at the same dosage, with no improvement in symptoms. Because the patient was a poor surgical risk, operative removal of the bezoar was felt hazardous. A third gastroscopy was performed on 3 December which again revealed an unchanged bezoar. Six tablets of pulverized Gastroenterase were suspended in 300 ml of warm water and injected directly into the bezoar through a catheter insered through the endoscope's biopsy channel. After 3 days, the patient became asymptomatic, and upper gastrointestinal radiography 10 days later failed to demonstrate evidence of residual material in the gastric pouch (Figure 2 B). The patient has remained symptom free for 6 months. DISCUSSION Untreated gastric bezoars have a significant mortality and morbidity.' Complications include gastric ulceration, upper gastrointestinal bleeding, intestinal obstruction, weight loss, and perforation. 1.' In the past several years, there has been a search for effective non-surgical modalities of therapy. In 1959, Dann et al. successfully utilized oral papain and sodium bicarbonate to dissolve a persimmon bezoar. 3 Nothing more was written about this form of management until 1968 when Cohen and Strika reported the successful treatment of four patients using similartherapy.4 Papain has been mainly successful in treating diospyrobezoars (viz., persimmons) but has been inconsistent in the in the treatment of other types of phytobezoars. 5.6 It has also been noted that the use of papain over a lengthy course may be ulcerogenic.? Because of these problems with meat tenderizer, other nonsurgical methods have been employed. The oral administration of ananase, a proteolytic enzyme derived from pineapple plants, was used successfully by Sparberg et al. to dissolve a phytobezoar composed of grape skins and pulp.· Pollard and Block first used the enzyme mixture Gastroenterase (pepsin 150 mg, pancreatic enzymes 100 mg, cellulase 25 mg, and dehydrocholic acid 50 mg) in the form of oral pulverized tablets to successfully dissolve a postgastrectomy phytobezoar. 9 Deal et al. were equally successful utilizing the same method. ' ° With the increasing use of panendoscopy, new methods of therapy have been introduced. In 1972 McKechnie reported the use of the gastroscope for mechanical disruption of a small bezoar." Others have simi larly employed both the endoscope and biopsy forceps.""'13In 1974 Davis and Faruqui reported the gastroscopic application of papain along the junction of
the bezoar's attachment to the gastric pouch." Other methods include the use of a liquid or low-residue diet and nasogastric suction. 12 Wholey et al. reported a fluoroscopically controlled technique employing a specialized snare for the capture and removal of a persimmon bezoar." Although phytobezoars are composed of plant debris, it is believed that proteolytic enzymes (i.e., papain and ananase) might be effective because they may disrupt protein bonds between cellulose fibers. "In vitro studies have shown dissolution of a persimmon suspension by papain without the additon of pepsin or hydrochloric acid. 3 It has been proposed that sodium bicarbonate adds to the efficacy of bezoar dissolution by a mucolytic action which dissolves the mucoid capsule, thereby allowing for more rapid contact between enzyme and mass." The use of cellulase for the dissolution of vegetable matter (cellulose) appears more logical and, indeed, has been successful in several instances. 9 • 10. 16 Unfortunately, none of the above methods which were utlized in our patients were successful. Because of past success by others with oral cellulase, we endoscopically injected pulverized Gastroenterase directly into the bezoar. Subsequently, dissolution of the bezoars occurred in both patients without untoward effects. Mechanical disruption done at the time of cellulase injection could have been responsible for the phytobezoar dissolution. This possibility seems unlikely since previous attempts at physical disruption were unsuccessful in both patients. It is interesting to speculate regarding the formation of the phytobezoar in our first patient. It is well known that postsurgical gastric bezoars form most commonly in patients with Billroth I anastamoses and vagotomy and pyloroplasty, respectively.' In addition to vagotomy and pyloroplasty, this patient had an unusual post-surgical antral contraction deformity which appeared to prevent passage of more proximal gastric contents. Complete dissolution of her bezoar was demonstrated at the time of surgery, and revision of the antral deformity resulted in resolution of symptoms. Although our method was used afterfailure of both mechanical disruption and oral enzyme ingestion, in retrospect we believe that this simple technique should be employed during initial gastrosopy. This method of bezoar dissolution may well obviate the need for hospitalization and may eliminate both complications and prolonged patient discomfort.
ACKNOWLEDGEMENTS: The authors wish to thank Dr. Daniel H. Gregory for his review of the manuscript and helpful suggestions.
REFERENCES 1. DEBAKEY M, OCHSNER A: Bezoars and concretions. Surgery 4:934,1938 2. DEBAKEY M, OCHSNER A: Bezoars and concretions. Surgery 5:132, 1939 3. DANN DS, RUBIN 5, PASSMAN H, DEOSARANSINGIL M, BAUERNFEIND A and BERENBOM B: The successful medical management of a phytobezoar.
Arch Intern Med 103:598, 1959 4. COHEN NN, STRIKA ZA: The medical treatment of bezoars. Gastrointestinal Endoscopy 14:144, 1968 5. GOLDSTEIN HM, COHEN lE, HAGEN RO, WELLS RF: Gastric bezoars- a frequent complication in the postoperative ulcer patient. Radiology 107:341,1973 6. RowEjS, jr, WHITAKER WG, Jr: Postgastrectomy phytobezoar. South Med 165:1452,1972 7. DUGAN FA, LILLY JD, MCCAFFERY TD, jr: Dissolution of a phytobezoar with short-term medical management. South Med 165:313,1972 8. SPARBERG M, NIELSEN A, ANDRUCZAK R: Bezoar following gastrectomy. Am I Dig Dis 13 :579, 1968
202
9. POLLAR HB, BLOCK GE: Rapid dissolution of phytobezoar by cellulase enzyme. Am I Surg 116:933, 1968 10. DEAL DR, VITALE P, RAFFIN SB: Dissolution of postgastrectomy bezoar by cellulase. Gastroenterology 64:467, 1973 11. McKECHNIE J: Gastroscopic removal of a phytobezoar. Gastroenterology 621047,1972 12. ROGERS IF, DAVIS EK, HARLE TS: Phytobezoar formation and food bali following gastric surgery. Am J Roentgenol 119:280, 1973 13. THOMPSON H, GREGORY DH: Mucous gastric bezoar. Gastrointestinal Endoscopy 20:69, 1973 14. DAVIS RC, FARUQUI AM: Endoscopic enzymatic dissolution. Non-surgical therapy for gastric phytobezoars. JAMA 229:1332, 1974 15. WHOLEY MH, ZIKRIA EA, MANSOOR M: Instrument for the removal of a gastric bezoar. Acta Radiol 15:333, 1974 16. BRUCK HM: Gastric phytobezoar. lAMA 231 :26, 1975
GASTROINTESTINAL ENDOSCOPY
Two cases of phytobezoar dissolution employing direct endoscopic injection of cellulase (Gastroenterase) after failure of previously described nonsurgical techniques are presented. This method of therapy may eliminate the need for hospitalization and may decrease both morbidity and prolonged patient discomfort. Since the advent of surgery in the management of peptic ulcer disease, the problem of gastric bezoar has become increasingly more prevalent. Until recently, the only available treatment was surgical intervention. The purpose of this report is to introduce a new and direct endoscopic technique for treating gastric phytobezoars. The following cases illustrate this simple method for bezoar dissolution which is heretofore undescribed in the literature. REPORTS OF CASES 1. A 47-year-old woman was referred to the Naval Regional Medical Center Hospital, Camp Lejeune, NC, in June 1974 for evaluation of abdominal pain. In August 1972 the patient had undergone an exploratory laparotomy with vagotomy and pyloroplasty for hemorrhage from a gastric ulcer in the proximal stomach. She did well until March 1974 when she noted the onset of epigastric and left upper quadrant cramping pain which began 15 to 20 minutes postprandially and persisted for 1 to 3 hours. The pain was always associated with ingestion of solid foods but not with liquids. The patient also noted early satiety and nausea without vomiting. During the 6 months before evaluation she had lost approximately 20 pounds. Physical examination was unremarkable. An upper gastrointestinal study revealed the presence of an irregular mass within the antrum, body, and fundus of the stomach which was fixed to the posterior wall (Figure 1A). In addition, a contraction ring was noted in the antrum, making identification of the true pylorus difficult. Subsequent gastroscopy revealed a 7 cm x 9 cm, green, gelatinous, adherent mass
on the posterior wall of the body and fundus of the stomach. Mechanical disruption with biopsy forceps was performed revealing an inflamed mucosa beneath the bezoar. The previously noted antral deformity was seen as a circumferential mucosal indentation appearing as a pseudopylorus through which peristalsis progressed poorly. The distal antrum, pylorus, and duodenum were normal and consistent with a surgical pyloroplasty with proximal antral surgical deformity. The patient was instructed to ingest commercial meat tenderizer (Adolph's), one-halfteaspoonful in applesauce 3 times daily. When reevaluated several weeks later, symptoms were unchanged. Repeated upper gastrointestinal radiography revealed persistence of the gastric bezoar, although smaller in size. We next attempted to dissolve the bezoar utilizing oral cellu lase. Th ree tablets of Gastroenterase (Wampole Laboratories, Stamford, Ct.), were crushed and swallowed with a glass of water after each meal for a period of 3 days. Her symptoms remained unchanged, and repeated gastroscopy on 25 September revealed the phytobezoar, unchanged in size or position. A second trial of Gastroenterase was made at the same dosage but extended to 7 day5, again without symptomatic improvement. In late November 1974, 6 Gastroenterase tablets were crushed and suspended in 300 ml of warm water. This solution was then injected directly into the body of the bezoar through a polyethylene catheter inserted through the biopsy channel of the gastroscope. Upper gastrointestinal radiographs taken 2 weeks later revealed no evidence of the bezoar (Figure 1B). Because of persistent symptoms, elective
From the Department of Internal Medicine, Naval Regional Medical Center, Camp Lejeune, North Carolina. The opinions expressed herein are those of the authors and cannot be construed as reflecting the views of the Navy Department or of the Naval Service at large. Reprint requests: M. H. Gold, MD, Department of Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23219.
200
GASTROINTESTINAL ENDOSCOPY
Figure 1. A, An irregular mass occupies the antrum, body, and fundus of the stomach. B, The fill ing defect is no longer apparenl 2 weeks after the bezoar was injecled with Gaslroenterase.
laparotomy was performed in January 1975. An anterior gastrotomy was made 5 cm from the esophagogastric junction, and thorough inspection of the stomach revealed no evidence of residual bezoar. A moderate stenosis of the antrum proximal to the pyloroplasty was noted. This was opened along the previous suture line, a web of mucosa extending from anterior to posterior at the level of the stenosis was taken down, and the pyloroplasty was reconstructed as a long Heineke-Mikulicl. procedure. The patient has been asymptomatic during the 4 months since discharge. 2. A 69-year-old woman presented to the Naval Regional Medical Center emergency room on 24 August 1974 complaining of sharp, intermittent, epigastric pain for 3 days. The pain was worsened by food, relieved by emesis, and unaffected by alkali ingestion. Her medical history included a cholecystectomy, mild essential hypertension, chronic obstructive pulmonary disease, and moderately severe depression with anxiety neurosis. In the early 1950's, she began a long course of medical therapy for an antral ulcer. In July 1970, she underwent laparotomy for a persistent antral defect seen on upper gastrointestinal series. At operation, a small hiatus hernia and a scarred proximal duodenum and antrum were found. A bilateral vagotomy, hemigastrectomy, and Billroth I anastomosis were performed. She experienced no further gastrointestinal symptoms until August 1974. Physical examination revealed findings consistent with chronic obstructive pu Imonary disease and was otherwise unremarkable. Upper gastrointestinal rad iography on 27 August revealed a nonhomogeneous, irregular mass filling the entire gastric remnant. In addition, a large amount of retained secretions was present in the stomach (Figure 2A). Gastroscopy was performed on 10 September, revealing an 8 cm x 10 cm gelatinous mass fixed to the gastric wall and extending from
the proximal body of the stomach to just proximal to the anastomosis (Figure 3.). Attempts to mechanically disrupt the mass with both the endoscope and the biopsy forceps were only partially successful. Shortly after the procedure the patient regurgitated several fragments of a green, gelatinous mass containing portions of undigested celery and onion skin. Repeated upper gastrointestinal radiography 8 days postgastroscopy showed numerous irregular filling defects in the gastric remnant consistent with residual bezoar. Because of persistent, although diminished symptoms, the patient was given a trial of Gastroenterase (3 pu Iverized tablets swallowed with water after each of 3 meals daily for 3 days). Gastroscopy
Figure 3. Gastroscopic view showing a heaped-up gelatinous bezoar (b) fixed to lhe gastric folds (f). The angularis (a) is seen in the upper
right of the photograph.
Figure 2. A, An inhomogeneous mass fills the gastric remnant. B, A normal remnant and gastroduodenostomy is seen 10 days after instillalion of Gastroenterase into the bezoar. VOLUME 22, NO.4, 1976
201
2 weeks later revealed persistence of the gastric bezoar which was again resistent to endoscopic disruption. A second trial of Gastroenterase was conducted, increasing the treatment period to 6 days at the same dosage, with no improvement in symptoms. Because the patient was a poor surgical risk, operative removal of the bezoar was felt hazardous. A third gastroscopy was performed on 3 December which again revealed an unchanged bezoar. Six tablets of pulverized Gastroenterase were suspended in 300 ml of warm water and injected directly into the bezoar through a catheter insered through the endoscope's biopsy channel. After 3 days, the patient became asymptomatic, and upper gastrointestinal radiography 10 days later failed to demonstrate evidence of residual material in the gastric pouch (Figure 2 B). The patient has remained symptom free for 6 months. DISCUSSION Untreated gastric bezoars have a significant mortality and morbidity.' Complications include gastric ulceration, upper gastrointestinal bleeding, intestinal obstruction, weight loss, and perforation. 1.' In the past several years, there has been a search for effective non-surgical modalities of therapy. In 1959, Dann et al. successfully utilized oral papain and sodium bicarbonate to dissolve a persimmon bezoar. 3 Nothing more was written about this form of management until 1968 when Cohen and Strika reported the successful treatment of four patients using similartherapy.4 Papain has been mainly successful in treating diospyrobezoars (viz., persimmons) but has been inconsistent in the in the treatment of other types of phytobezoars. 5.6 It has also been noted that the use of papain over a lengthy course may be ulcerogenic.? Because of these problems with meat tenderizer, other nonsurgical methods have been employed. The oral administration of ananase, a proteolytic enzyme derived from pineapple plants, was used successfully by Sparberg et al. to dissolve a phytobezoar composed of grape skins and pulp.· Pollard and Block first used the enzyme mixture Gastroenterase (pepsin 150 mg, pancreatic enzymes 100 mg, cellulase 25 mg, and dehydrocholic acid 50 mg) in the form of oral pulverized tablets to successfully dissolve a postgastrectomy phytobezoar. 9 Deal et al. were equally successful utilizing the same method. ' ° With the increasing use of panendoscopy, new methods of therapy have been introduced. In 1972 McKechnie reported the use of the gastroscope for mechanical disruption of a small bezoar." Others have simi larly employed both the endoscope and biopsy forceps.""'13In 1974 Davis and Faruqui reported the gastroscopic application of papain along the junction of
the bezoar's attachment to the gastric pouch." Other methods include the use of a liquid or low-residue diet and nasogastric suction. 12 Wholey et al. reported a fluoroscopically controlled technique employing a specialized snare for the capture and removal of a persimmon bezoar." Although phytobezoars are composed of plant debris, it is believed that proteolytic enzymes (i.e., papain and ananase) might be effective because they may disrupt protein bonds between cellulose fibers. "In vitro studies have shown dissolution of a persimmon suspension by papain without the additon of pepsin or hydrochloric acid. 3 It has been proposed that sodium bicarbonate adds to the efficacy of bezoar dissolution by a mucolytic action which dissolves the mucoid capsule, thereby allowing for more rapid contact between enzyme and mass." The use of cellulase for the dissolution of vegetable matter (cellulose) appears more logical and, indeed, has been successful in several instances. 9 • 10. 16 Unfortunately, none of the above methods which were utlized in our patients were successful. Because of past success by others with oral cellulase, we endoscopically injected pulverized Gastroenterase directly into the bezoar. Subsequently, dissolution of the bezoars occurred in both patients without untoward effects. Mechanical disruption done at the time of cellulase injection could have been responsible for the phytobezoar dissolution. This possibility seems unlikely since previous attempts at physical disruption were unsuccessful in both patients. It is interesting to speculate regarding the formation of the phytobezoar in our first patient. It is well known that postsurgical gastric bezoars form most commonly in patients with Billroth I anastamoses and vagotomy and pyloroplasty, respectively.' In addition to vagotomy and pyloroplasty, this patient had an unusual post-surgical antral contraction deformity which appeared to prevent passage of more proximal gastric contents. Complete dissolution of her bezoar was demonstrated at the time of surgery, and revision of the antral deformity resulted in resolution of symptoms. Although our method was used afterfailure of both mechanical disruption and oral enzyme ingestion, in retrospect we believe that this simple technique should be employed during initial gastrosopy. This method of bezoar dissolution may well obviate the need for hospitalization and may eliminate both complications and prolonged patient discomfort.
ACKNOWLEDGEMENTS: The authors wish to thank Dr. Daniel H. Gregory for his review of the manuscript and helpful suggestions.
REFERENCES 1. DEBAKEY M, OCHSNER A: Bezoars and concretions. Surgery 4:934,1938 2. DEBAKEY M, OCHSNER A: Bezoars and concretions. Surgery 5:132, 1939 3. DANN DS, RUBIN 5, PASSMAN H, DEOSARANSINGIL M, BAUERNFEIND A and BERENBOM B: The successful medical management of a phytobezoar.
Arch Intern Med 103:598, 1959 4. COHEN NN, STRIKA ZA: The medical treatment of bezoars. Gastrointestinal Endoscopy 14:144, 1968 5. GOLDSTEIN HM, COHEN lE, HAGEN RO, WELLS RF: Gastric bezoars- a frequent complication in the postoperative ulcer patient. Radiology 107:341,1973 6. RowEjS, jr, WHITAKER WG, Jr: Postgastrectomy phytobezoar. South Med 165:1452,1972 7. DUGAN FA, LILLY JD, MCCAFFERY TD, jr: Dissolution of a phytobezoar with short-term medical management. South Med 165:313,1972 8. SPARBERG M, NIELSEN A, ANDRUCZAK R: Bezoar following gastrectomy. Am I Dig Dis 13 :579, 1968
202
9. POLLAR HB, BLOCK GE: Rapid dissolution of phytobezoar by cellulase enzyme. Am I Surg 116:933, 1968 10. DEAL DR, VITALE P, RAFFIN SB: Dissolution of postgastrectomy bezoar by cellulase. Gastroenterology 64:467, 1973 11. McKECHNIE J: Gastroscopic removal of a phytobezoar. Gastroenterology 621047,1972 12. ROGERS IF, DAVIS EK, HARLE TS: Phytobezoar formation and food bali following gastric surgery. Am J Roentgenol 119:280, 1973 13. THOMPSON H, GREGORY DH: Mucous gastric bezoar. Gastrointestinal Endoscopy 20:69, 1973 14. DAVIS RC, FARUQUI AM: Endoscopic enzymatic dissolution. Non-surgical therapy for gastric phytobezoars. JAMA 229:1332, 1974 15. WHOLEY MH, ZIKRIA EA, MANSOOR M: Instrument for the removal of a gastric bezoar. Acta Radiol 15:333, 1974 16. BRUCK HM: Gastric phytobezoar. lAMA 231 :26, 1975
GASTROINTESTINAL ENDOSCOPY
