• diagnosis
• gastro-intestinal
• acute medicine-other
• clinical assessment

A woman in her 40s presented to the emergency department with vomiting and sudden onset of dysphagia to liquids and solids. She had a history of achalasia. Initial blood tests and chest X-ray were normal. The working diagnosis was recurrence of achalasia.

An upper gastrointestinal (GI) endoscopy was arranged as part of her investigations. At endoscopy, cream-coloured mass was identified (see figure 1) and removed. It measured 5×5 cm² and had a minty aroma. The patient later admitted to swallowing up to three packets of chewing gum per day. The vomiting and dysphagia resolved following removal of the chewing gum bezoar.

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Figure 1

Endoscopic image of chewing gum bezoar.

Bezoars are retained concretions of undigested foreign material that accumulate and coalesce within the GI tract, most commonly in the stomach. They can be composed of virtually any substance, including food, hair, medications and plant material. Predisposing risk factors for bezoar formation include gastric surgery (typically partial gastrectomy and pyloroplasty), impaired gastric motility, autonomic neuropathy in diabetic patients and myotonic dystrophy. Treatment options include surgery, endoscopic removal, prokinetic drugs or enzymatic destruction. Emergency physicians should be aware of bezoars as a cause of dysphagia, as prompt diagnosis and removal are vital to prevent complications such as ulceration and obstruction.