Obstruction in the third portion of the duodenum due to a diospyrobezoar: a case report

Abstract

BackgroundDuodenal obstruction occurs mainly due to physical lesions such as duodenal ulcers or tumors. Obstruction due to bezoars is rare. We describe an extremely rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy for early gastric cancer.Case presentationA 73-year-old man who underwent laparoscopic distal gastrectomy for early gastric cancer 15 months before admission experienced abdominal distension and occasional vomiting. The symptoms worsened and ingestion became difficult; therefore, he was admitted to our department. Computed tomography (CT) performed on admission revealed a solid mass in the third portion of the duodenum and dilatation of the oral side of the duodenum and remnant stomach. Esophagogastroduodenoscopy (EGD) revealed a bezoar deep in the third portion of the duodenum. We could neither remove nor crush the bezoar. At midnight on the day of EGD, he experienced sudden abdominal pain. Repeat CT revealed that the bezoar had vanished from the duodenum and was observed in the ileum. Moreover, small bowel dilatation was observed on the oral side of the bezoar. Although CT showed neither free air nor ascites, laboratory data showed the increase of leukocyte (8400/μL) and C-reactive protein (18.1 mg/dL), and abdominal pain was severe. Emergency surgery was performed because conservative treatment was considered ineffective. We tried advancing the bezoar into the colon, but the ileum was too narrow; therefore, we incised the ileum and removed the bezoar. The bezoar was ocher, elastic, and hard, and its cross-section was uniform and orange. The postsurgical interview revealed that the patient loved eating Japanese persimmons (Diospyros kaki); therefore, he was diagnosed with a diospyrobezoar. His postoperative progress was good and without complications. He left the hospital 10 days after surgery. EGD performed 4 weeks after surgery revealed no abnormal duodenal findings.ConclusionsWe describe a rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer.

Pathophysiological and clinical aspects of the diagnosis and treatment of bezoars

“…Typically, they appear as single masses in the gastric fundus, with various colors (black, green, beige or other, according to composition). However, they may be multiple or very rarely be impacted in the esophagus or duodenum [4,48,49].…”

Unveiling a Silent Obstructor: Phytobezoar in the Third Duodenal Segment

“…Obstruction of the third portion of the duodenum secondary to a phytobezoar is a rare entity with limited documentation in the literature (Yamagata et al, 2017). Our case is noteworthy due to the site of obstruction and the absence of surgical history or exclusively vegetarian dietary patterns.…”

“…Phytobezoars located in the duodenum are extremely rare (Fan et al, 2016), with a reported incidence of less than 0.4% in the general population (Fan et al, 2016), and even rarer in the third portion of the duodenum (Yamagata et al, 2017).…”