Abstract

To the Editor:A 57-year-old male patient presented with vomiting 2 hours after a meal; he had also been experiencing abdominal pain, constipation and obstipation for 2 weeks. One week earlier, at another healthcare center, an upper gastrointestinal system endoscopic examination showed phytobezoar at the bulbus, reflux gastritis and gastric ulcer. He had no gastric surgery but had a history of eating persimmons and subclinical diabetes. On physical examination, epigastric tenderness and clapotage was determined. Both erytrocyte sedimentation rate (68 mm/h) and C-reactive protein were high (52 mg/L). Vitamin B12 level was low (130 pg/mL, range 160–900 pg/mL). Plain abdominal radiography showed gaseous distention of the small bowel. Repeated endoscopic examination showed esophagitis stage 2, alkaline reflux pangastritis and gastric and duodenal ulcer. Colonoscopic examination was normal. Electromyogram revealed sensorial and motor polyneuropathy. Abdominal ultrasonography showed dilated small bowel loops and hydropic gallbladder. CT imaging demonstrated a round, heterogenous, intraluminal-mottled appearance mass, including gas, hyperdense bodies and soft tissue in the jejunum. The bowel loops proximal to the mass were dilated. Collapsed loops of small bowel were seen immediately beyond this lesion (Fig.). The CT findings suggested an obstructive bezoar. A small bowel barium study showed dilated small bowel loops and a few number of diverticules of the small bowel. Transmission of contrast material was also delayed (approximately 9 hours). During the barium study, defecation of the phytobezoar was observed. The other fragment was defecated just after the study. When the patient was hospitalized, oral uptake was stopped, the nasogastric tube was placed, and medical treatment, including parenteral fluid, pantoprozole, domperidone, ceftriaxone, metronidazole and vitamin B12 replacement, was given.