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Volume 7, Issue 9 , Pages e51-e52, September 2009

Obstructing Small Bowel Phytobezoar Successfully Treated With an Endoscopic Fragmentation Using Double-Balloon Enteroscopy

published online 10 April 2009.

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.