The probability of discovering bezoars through gastroscopy is rare at approximately 0.3% [1,5]. Bezoars may form due to anatomical abnormalities in the stomach resulting from a previous gastric surgery such as subtotal gastrectomy, vagotomy, or pyloroplasty. These surgical histories are associated with changes in gastric motor function, including delayed gastric emptying, decreased gastric accommodation, reduced peptic activity, and poor gastric mixing. Conversely, among patients with bezoars who have not undergone a surgical treatment, gastroparesis and the use of anticholinergics or opiates may occur due to changes in gastric motility. Additionally, underlying conditions such as inadequate mastication, high-fiber diets, diabetes mellitus, chronic renal failure, and psychiatric disorders may promote bezoar formation [3,6,7].

To treat gastrointestinal bezoars, methods such as surgical, endoscopic removal, or chemical dissolution have been used [3]. Endoscopic methods include fragmentation and removal using biopsy forceps, polypectomy snare, electrohydraulic lithotripsy, argon plasma coagulation, electrosurgical knife, baskets, etc. However, the treatment method for bezoars has not been clearly established. Treatment for patients with bezoars must first consider whether there is intestinal obstruction or severe bleeding. Patients with intestinal obstruction or severe bleeding require an emergency surgery. However, it is necessary to evaluate the nature of the bezoar in patients without intestinal obstruction or severe bleeding. Trichobezoars and bezoars composed of vinyl gloves require endoscopic or surgical treatment [3]. Phytobezoars can be treated using chemical dissolution agents such as carbonated beverages like Coca-Cola and proteolytic enzymes like acetylcysteine, cellulase, and papain in addition to endoscopic or surgical removal [3]. Since the first case report in Korea in 2006, Coca-Cola has been used to remove bezoars, reducing complications associated with surgical methods [3,8]. Coca-Cola maintains an acidity of pH 2.6, similar to that of normal stomach acid. It can activate proteolytic enzymes in the stomach to facilitate the dissolution of bezoars. Additionally, sodium bicarbonate in Coca-Cola can promote mucus dissolution. The carbon dioxide generated from carbonic acid is believed to cause gas bubbles to penetrate the bezoar and digest its fibers [3,9]. Methods of administering Coca-Cola include drinking it by mouth, gastric lavage through a nasogastric tube, or injecting it directly into the bezoar using an endoscope[3,10,11]. Ladas et al. [12] suggested gastric lavage or drinking 3 L of Coca-Cola over 12 hours, but there is no established protocol regarding the amount and timing of Coca-Cola administration. Proteolytic enzymes do not seem to be universally used [4]. The reason is because acetylcysteine has a low success rate [10]. Cellulase has the disadvantages of being expensive and not being universally available in many countries [3]. Additionally, papain can cause gastric ulcer or esophageal perforation in some patients who receive treatment [11].

In this issue of the Korean Journal of Helicobacter and Upper Gastrointestinal Research, the two articles on gastric bezoars including an original article on the chemical dissolution of phytobezoars using carbonated beverages (Coca-Cola) and a case report on surgical treatment provide valuable data in the context of the ongoing lack of a clear treatment for gastric bezoars [13,14]. The former study was conducted at a single institution. It reviewed 15 cases of gastric phytobezoars where patients were treated primarily with Coca-Cola [13]. As a result, approximately 80.0% of patients were successfully treated either with carbonated beverages alone or with additional endoscopic management using various devices such as lithotripters, net and snares. In particular, bezoars were resolved in 46.7% of cases with carbonated beverages alone. However, treatment with Coca-Cola requires drinking large amounts (1.5–3 L/day for 1–2 days), which might cause patient discomfort. Additionally, the treatment period is long, taking about 2 days to 14 days for the bezoar to be removed after Coca-Cola administration. Above all, it is important to note that 20.0% of patients in this study required surgical treatment for small bowel obstruction caused by migration of a fragmented bezoar.

This case report on gastric bezoars offers reflections on limits of non-surgical methods and the important role of surgical intervention in certain cases [14]. In the first case of a 63-year-old woman, despite repeated attempts to spray or drink carbonated beverages with endoscopic treatment, gastric phytobezoars, accompanied by complications such as mechanical ileus, eventually necessitated surgical removal. In the second case of a 6-year-old girl, a large recurrent trichobezoar due to pica, unmanageable through endoscopic resection using snare and electrocoagulation due to its size and density, also required surgical intervention. Therefore, when selecting chemical dissolution, endoscopic treatment, or surgical treatment, it is crucial to consider the size, composition, and location of the bezoar. To this end, evaluating the effectiveness of each treatment method through various case studies and establishing standards for treatment is essential to making informed decisions.

When choosing bezoar treatment, clinical outcomes, including patient safety and complications, are of paramount importance. Understanding advantages and disadvantages of chemical dissolution, endoscopic treatment, and surgery is crucial for selecting the optimal approach tailored to the patient’s specific condition. This retrospective study has confirmed the applicability of Coca-Cola for phytobezoar treatment [13]. However, it is important to inform patients about the possibility of small bowel obstruction before drinking carbonated beverages. Although the analysis conducted in the study did not find any significant differences between a carbonated beverage treatment success group and a failure group, the failure group tended to be older and have a larger bezoar size. In addition, persimmon phytobezoars may be resistant to carbonated beverages due to their harder consistency [15]. Therefore, carbonated beverages could become a viable treatment option if appropriate indications based on the patient’s specific circumstances and characteristics of the bezoar are established.

Moreover, this case report reminds us of the importance of addressing underlying causes, such as psychiatric illnesses like trichotillomania and pica, that may contribute to the development of trichobezoars [14]. The management of bezoars, particularly in patients with repeated occurrences, is not merely about removing the bezoars but also about providing comprehensive care that includes addressing behavioral or psychological factors contributing to the condition.

Comparative analysis of clinical outcomes using carbonated beverages among various patient groups is necessary to refine protocols for carbonated beverage treatment, identify patient profiles that predict successful outcomes without complications, and develop guidelines to effectively monitor patients during and after treatment. Further studies in this regard are anticipated.