In this eight-year single-center retrospective study, it was shown that phytobezoars are most common in children, congenital GIS anomalies play an important role in the etiology, and that these anomalies mostly cause bezoar formation in early childhood. A series of 7 cases in 10 years was reported by Castle et al. , and a series of 4 cases in 18 years was reported by Gorter et al.  in the literature.
In studies conducted in adult patient groups, it was reported that bezoar formation may develop in any region of the GIS, but mostly in the stomach . As far as we know, the region of the GIS in which bezoar formation occurs most in childhood has not been reported in any study in the literature to date. In the present study, it was found that in more than half of the cases, bezoar developed in the stomach or stomach and duodenum region.
In studies conducted, it has been reported that phytobezoar is the most common type of bezoar . Similar to studies in the literature, vegetable nutrients were detected in approximately two-thirds of patients in the present study. It has been reported that among vegetable nutrients, persimmon is the most common cause of the formation of phytobezoars . In this study, as in other studies in the literature, it was determined that the vegetable nutrients shown as the sole etiological factor for phytobezoar formation were persimmon and hazelnut.
Many studies have reported numerous etiological factors for bezoar formation, such as mental retardation, trichotillomania, GIS surgery, a high intake of high fiber vegetable matter over a short period, and raw vegetable nutrient intake. It has been reported that gastric surgeries are the most common etiological factor for bezoar formation in adult patient groups . As far as we know, there are not enough data in the literature about the frequency of risk factors in childhood. In the present study, it was shown that congenital GIS anomalies, especially duodenal anomalies, were in the etiology of bezoar formation, with a rate of 37.5%.
In the literature, a case of bezoar was reported by Chien et al. due to duodenal web in a 2-year-old patient, who was previously healthy . In the present study, the oldest of the 3 patients with duodenal web was 3.5 years old. While 2 of these patients had no prior history of duodenal obstruction, 1 had received medical treatment and endoscopy for bezoar. Of the patients in this group, 2 had phytobezoars and 1 had lactobezoars. In addition, the patient with duodenal hyperfixation had trichotillomania, and trichobezoar was also detected. In the literature, Meckel’s diverticulum accompanying bezoar was reported in several cases during childhood and it was reported that it was mostly of the phytobezoar type. One of them was Meckel’s diverticulitis, accompanied by phytobezoars in a 12-year-old patient reported by Gasparella et al. . Similarly, in the present study, phytobezoar presented at the Meckel’s diverticulum in one case and also accompanied Meckel’s diverticulitis. In the literature, 2 cases of annular pancreas, which were responsible for bezoar formation, were reported, with one of them reported by Kestel et al. in an adult patient, who had recurrent pancreatitis due to bezoar . In the present study, the patient in whom the annular pancreas was detected was 2 years old and had had no previous complaints.
It has been reported that trichobezoars are mostly seen in patients with psychiatric disorders, especially trichotillomania and depression, and 14% of these patients were under 7 years of age . Similar to the studies in the literature, 2 patients with trichobezoar were also diagnosed with trichotillomania in this study. One of these patients had accompanying duodenal hyperfixation anomaly and was under 7 years of age.
In many studies in the literature, it has been reported that patients with mental retardation can ingest many nonnutrients, especially hair, and bezoar forms as a result . In 1 of 2 patients with mental retardation, bezoar occurred as a result of their ingesting plastic material, while phytobezoar was detected in the other. Similarly, of the 2 patients, who were too young to properly distinguish between nutrients and non-nutrients, one had bezoar due to their ingesting chewing gum and the other had bezoar due to their ingesting play dough.
It has been reported that excessive consumption of high-fiber vegetable foods may cause phytobezoar formation, particularly if immature fruits or vegetables are swallowed in large quantities without sufficient mastication, as they pose a risk for bezoar formation. In particular, immature kaki persimmons in this group of vegetable foods cause phytobezoar formation . In the present study, similar to the literature, phytobezoars occurred in 2 cases without any risk factors after the intake of a large amount of persimmon over a short period. Similarly, in one case, phytobezoars occurred after the intake of a large amount of hazelnuts in a short time.
Bezoars have been reported to occur in conditions such as intestinal diverticulum, neoplasm, and as a result of surgical procedures, which reduce intestinal motility . In this study, as noted in the literature, phytobezoars occurred in 2 cases where patients did not follow their prescribed diets after appendicitis surgery and consumed excessive amounts of high-fiber vegetable matter.
In this study, the aim was to draw attention to bezoar types seen in childhood and the risk factors that play a role in bezoar formation. However, the small number of cases is a limitation of this study. It is thought that large-scale studies are needed on this subject.