A Large-Sized Phytobezoar Located on the Rare Site of the Gastrointestinal Tract
A 71-year-old male, who 8 years previously had undergone subtotal gastrectomy with gastroduodenostomy because of early gastric cancer, came to the Department of Emergency with severe epigastric discomfort, abdominal pain and vomiting of 3 days' duration. He had a history of diabetes mellitus for 14 years and was using 12 IU of insulin daily. Despite using insulin, his blood glucose level was not strictly controlled, usually ranging from 250 to 300 mg/dL. The latest hemoglobin A1c level checked 6 months earlier was 7.3%. He had also been diagnosed with end-stage renal disease (ESRD) 6 years previously and had hemodialysis three times a week since then.\nOn clinical examination, he was drowsy with disorientation. His vital signs were within the normal range. Chest and cardiac findings were unremarkable. The abdomen was not distended, and no mass was palpable. Laboratory test results showed a hemoglobin concentration of 10.4 g/dL, a leukocyte count of 6.4×103 g/µL, and a platelet count of 85×103/µL. His serum creatinine was 8.48 mg/dL and urea nitrogen was 45 mg/dL, which had not increased since the previous lab results obtained 1 month earlier. Amylase and lipase were increased up to 848 and 272 U/L, respectively. The serum glucose level was only 38 mg/dL. After immediate intravenous glucose solution infusion, his mental status improved. The rest of his biological examination results were normal.\nAbdominal radiography showed a normal bowel gas pattern and no significant abnormalities. The patient underwent an abdominal pelvic computed tomography (CT) scan to evaluate the cause of his gastrointestinal symptoms. The CT scan revealed 7×8 cm-sized well-defined duodenal mass including gas bubble inside (). Mild pancreatic duct dilatation was also observed. An esophagogastroduodenoscopy was then performed to obtain accurate diagnosis. The anastomosis site was intact without any stricture; however, directly under the anastomosis site, a huge, dark greenish bezoar was confirmed in the duodenum (). There were also many small ulcers on the periphery of the bezoar. We attempted to pull the bezoar out into the gastric cavity for fragmentation by lithotripsy, which was failed because it was tightly adhering to the lumen of the duodenum. Therefore, we injected 50 mL of Coca-Cola directly to the bezoar in order to reduce its size and soften its consistency. Thirty minutes after the Coca-Cola injection, we attempted to move the bezoar using an alligator forceps (FG-47L-1; Olympus, Tokyo, Japan) and a snare (MTW Endoskopie, Wesel, Germany), which failed again. The patient was admitted to the General Ward from the Emergency Room for further treatment. Three nasogastric lavages were performed using 1.5 L of Coca-Cola every 12 hours with a proton pump inhibitor injection and glucose control by insulin. The next endoscopy demonstrated that the bezoar had become smaller and softer. It could finally be pulled out into the gastric cavity using an alligator forceps and was broken into small pieces by lithotripsy (Lithotriptor handle; Medi-globe, Hachenmuhle, Germany) (). The fragmented pieces were successfully removed using a snare and a basket (MTW Endoskopie). Inspection demonstrated that the removed bezoar was a phytobezoar ().\nAbdominal radiography performed just after the complete endoscopic removal showed no evidence of bowel obstruction. With appropriate intravenous nutritional support using insulin, the patient's serum glucose level was maintained within the normal range. Three days after the complete endoscopic removal, the patient was examined again through second-look endoscopy. No residual bezoar was seen, although small ulcers caused by local pressure on the duodenal wall were observed (). The patient was discharged with instructions to maintain sufficiently soft diet. Since his discharge, he has had no subsequent episode of abdominal pain or vomiting. On follow-up endoscopy performed 3 months later, no recurrence of a bezoar was noted and his ulcers were completely healed ().