Volume 7, Issue 9 , Pages e51-e52, September 2009
Obstructing Small Bowel Phytobezoar Successfully Treated With an Endoscopic Fragmentation Using Double-Balloon Enteroscopy
Article Outline
A 68-year-old woman presented to our hospital because of a 3-day history of epigastric pain and bilious vomiting. She had undergone a pyloroplasty for perforated peptic ulcer 15 years previously and a hysterectomy for uterine myoma 10 years previously. The patient reported multiple years of ingesting fragrant manjack (Cordia dichotoma Forst. f.), which are called Pho Pu Zi in Taiwan. An esophagogastroduodenoscopy performed at another hospital revealed gastric and duodenal ulcers. On physical examination, her upper abdomen was tender with rebound tenderness. Laboratory tests revealed a white blood count of 12,390 mm3 (normal, 4000-10,000 mm3). The results of other tests were unremarkable. Abdominal plain radiograph revealed dilated bowel loops with air-fluid levels in the right upper quadrant, suggesting an obstruction in the duodenum. Abdominal computed tomography (CT) scan demonstrated pronounced dilatation of the stomach and the proximal portion of duodenum with significant fluid content (Figure A). Moreover, a well-defined, ovoid-shaped intraluminal mass with mottled gas pattern in the mid-third portion of the duodenum and an abruptly collapsed lumen beyond the lesion were clearly identifiable (Figure B). An upper gastrointestinal series performed 2 days later disclosed a large irregular filling defect impacted in the proximal jejunum (Figure C). Antegrade double-balloon enteroscopy (DBE) demonstrated the presence of multiple circular and linear ulcers extending from the duodenum to the proximal jejunum. Finally, a large phytobezoar (5 cm or greater in diameter) completely obstructing the bowel lumen was identified in the proximal jejunum (Figure D). An attempt to remove the phytobezoar using an electrosurgical snare and a Dormia basket resulted in fragmentation of the phytobezoar (Figure E). The fragmented phytobezoars were able to move back and forth in the bowel lumen after partial endoscopic fragmentation. Follow-up small bowel series performed 2 days later revealed no evidence of intestinal obstruction.
Phytobezoars are an uncommon cause of small bowel obstruction, accounting for about 4.3% of all cases.1 Small bowel phytobezoars are difficult to diagnose preoperatively and usually depend on radiological evidence and endoscopic techniques. Abdominal plain radiographs typically show a classic obstructive pattern of dilated small bowel loops containing air-fluid levels. Barium studies characteristically reveal an intraluminal filling defect of variable size that does not appear to be fixed to the bowel wall. On ultrasound, a phytobezoar presents as a hyperechoic intraluminal mass with an arclike surface and prominent acoustic shadowing. Small bowel phytobezoar typically presents on abdominal CT as a well-defined, ovoid-shaped intraluminal mass containing mottled gas, a structure referred to as a “fecal ball” or “small bowel feces.”2 Conventionally, surgical intervention via laparotomy or laparoscopy is the mainstay of choice in treating small bowel phytobezoars.3 However, small bowel phytobezoars are difficult to remove endoscopically because of endoscopic inaccessibility. To date, this is the first case of an obstructing small bowel phytobezoar that was successfully treated with an endoscopic fragmentation using DBE.
References
- . Small-bowel obstruction secondary to bezoar impaction: a diagnostic dilemma. World J Surg. 2007;31:1072–1078discussion 1079–1080
- CT findings of phytobezoar associated with small bowel obstruction. Eur Radiol. 2003;13:299–304
- Laparoscopic management of intestinal obstruction due to phytobezoar. JSLS. 2007;11:168–171
Conflicts of interest The authors disclose no conflicts.
PII: S1542-3565(09)00322-X
doi:10.1016/j.cgh.2009.03.026
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
Volume 7, Issue 9 , Pages e51-e52, September 2009
