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We illustrate a rare late onset (10 yr) complication of gastric surgery with a combination of afferent loop syndrome and a large duodenal bezoar. The patient underwent a subtotal gastrectomy with Billroth II gastrojejunal anastomosis for benign peptic ulcer 10 yr ago. It was not until several days before this presentation that he suffered from epigastralgia and abdominal distension. Leukocytosis and abnormal blood biochemistry were found including amylase, lipase, alkaline phosphatase, total bilirubin, GOT, and GPT in which amylase was markedly elevated to 1188 U/L. Abdominal ultrasound scan and especially CT scan confirmed the diagnosis of a large bezoar in the dilated duodenal afferent loop. To our knowledge, the rare entity in our case is the first reported in the literature.

Six cases of gastric phytobezoars were seen on fiberoptic gastroscopy over a period of four years during which time 1,400 gastroscopies were done. Four of these cases showed complete resolution of bezoars on repeat endoscopy during a follow-up period ranging from two weeks to one year. Our experience shows that, in the absence of gastric outlet obstruction, small bowel obstruction or other serious problems due to bezoars, they may not need surgical or aggressive medical treatment.

Agave americana is a cactus growing abundantly in Mexico. Its cooked stem ("quiote") yields by mastication a sweet juice which is swallowed, while the fibers ("bagazo") are spit out. That is the way Mexicans are taught to chew quiote since their early childhood, and it accounts for the rarity of bezoars from this origin. One of such cases is reported herein.

A white 65-yr-old male who presented with epigastric pain and early satiety had a gastric bezoar composed of multiple lupini beans. Surgical removal was required due to the hard consistency of the mass. Gastric lupinomas has become a serious clinical problem, since lupini beans are currently used by unorthodox healers as an alleged treatment for arthritic pain.

A full-term, healthy, breast-fed infant presenting with apnea and cyanosis was found to have a gastric bezoar during a contrast upper gastrointestinal study. The condition resolved spontaneously, with no recurrence of symptoms after resumption of feeding. This represents an unusual case, in that the infant had none of the previously described predisposing factors to bezoar formation.

A 35-yr-old man with hematemesis, epigastric pain, and no predisposing factors to delayed gastric emptying was found to have a gastric bezoar. Surgical removal was required. Pathological and biochemical examination revealed a mass composed of polystyrene. This represents an unusual composition and a newly recognized predisposing factor to bezoar formation, "polystyrenomania" from ingestion of styrofoam cups.

A phytobenzoar formed in an intact stomach due to the excessive intake of citrus fruit. This was successfully treated by the combined use on a multienzyme preparation to soften it followed by its endoscopic destruction.

Gastric bezoars may occur in the normal stomach as a result of ingestion of various objects which do not pass through the pylorus. Most gastric bezoars occur as a complication of previous gastric surgery in which there is a loss of normal pyloric function, hypoperistalsis, and low gastric acidity. They may also occur as a complication of cimetidine therapy. Symptoms include epigastric fullness, regurgitation, nausea and vomiting, and epigastric pain. A simple treatment utilizing an ordinary Teledyne Water Pik jet stream through a gastroscope is described to break up a large phytobezoar. This method is probably the treatment of choice and should be used more widely.

Sixteen cases of postgastrectomy bezoars were diagnosed and treated in the period of five years. Various mechanisms of their information, symptomatology and therapy are discussed. We believe postgastrectomy bezoars are relatively frequent but often missed entities. Considering the relative frequency of this entity and ease of therapy, this condition should not be missed if one is aware of its existence.

The manifestations of myxedema often occur insidiously over several months or years. Except for gastrointestinal symptoms, the diagnosis of hypothyroidism may not clinically evident. Especially in the elderly, symptoms of hypothyroidism are frequently unrecognized or simply dismissed as signs of old age.