An Unusual Cause of Gastrointestinal Obstruction: Bezoar

    Tariq O. Abbas  


  DOI 10.5001/omj.2011.31  
From the Department of Pediatric Surgery Hamad General Hospital, Doha, Qatar.

Received: 05 Oct 2010
Accepted: 11 Dec 2010

Address correspondence and reprints request to: Dr. Tariq O. Abbas Department of Pediatric Surgery Hamad General Hospital, Doha, Qatar.

How to cite this article

Abbas TO. An Unusual Cause of Gastrointestinal Obstruction: BezoarOman Med J 2011 March; 26(2):127-128.

How to cite this URL

Abbas TO. An Unusual Cause of Gastrointestinal Obstruction: BezoarOman Med J 2011 March; 26(2):127-128. Available from



Bezoars are concretions of swallowed hair, fruit vegetable fibers, and similar substances found in the alimentary canal. The first description of a postmortem human bezoar was by Swain in 1854. Although the prevalence of bezoars in humans is low, an absence of treatment has been associated with mortality rates as high as 30%, primarily because of gastrointestinal bleeding, destruction, or perforation.


This is a report describing acute intestinal obstruction due to a phytobezoar following truncal vagotomy and gastrojejunostomy in
a 68-year-old man.

Case Report

A 68 year-old male who had undergone a gastrojejunostomy seven years earlier as part of his surgical management for a duodenal ulcer refractory to medical treatment presented with epigastric discomfort, abdominal pain and vomiting  of 10 days duration. Physical examination showed that he was afebrile, with a pulse rate of 138 beats/min and a respiratory rate of 28/min. Chest and cardiac findings were unremarkable. The abdomen was soft and non-tender and not distended. No focal neurologic deficits were apparent.

 Laboratory test results showed a hemoglobin concentration of 16.9 g/dL, a leukocyte count of 13 x 109 /L, and a platelet count of 351 x 109 /L. His serum creatinine was 366 mg/dl, his urea nitrogen was 24.5 mg/dl, his Na concentration was 130 mEq/L and his serum glucose concentration  was 25.11 mg/dl. Upper GI contrast study showed a persistently dilated proximal jejunal loop. (Fig. 1)


Figure 1: Barium study showing mid-jejunal opacity with a claw- like appearance. The bowel loop distal to the filling  defect has collapsed (arrow).

Despite the administration of intravenous fluids and cessation of oral feeding, the patient continued to vomit continuously. An exploratory laparotomy through  an  upper  midline abdominal incision revealed a hard, mobile mass causing a complete obstruction in the jejunum. The mass was exteriorized through an enterotomy, (Fig. 2). The mass had a rough, greenish-black outer surface, which appeared whitish due to the contrast used in the upper GI study. His postoperative period was unremarkable, other than mild vomiting during the first two days.


Figure 2:  Removal  of  the  bezoar  through  laparotomy and enterotomy from the mid-loop of the jejunu


Bezoars occur most frequently in patients with a previous history of gastric operation and are detected in up to 20% of patients who have undergone antrectomy.1 Phytobezoar formation may be due to a reduction in gastric acidity, peptic activity, poor gastric mixing, and/or delayed emptying.2

The diagnosis of a gastric trichobezoar can be confirmed by radiography or endoscopy. Plain films of the abdomen may reveal amorphous, granular, calcified, or whirlpool-like configurations of solid and gaseous material within the stomach.3 Unlike phytobezoars, which are generally impervious to barium, trichobezoars tend to absorb barium, aiding in their diagnosis. The current gold standard for diagnosis of bezoars is upper gastrointestinal endoscopy, which provides direct visualization of the bezoar and allows sample taking and therapeutic intervention.4

Sonographic  evidence of an intraluminal mass with a hyper- echoic arc-like surface and a marked acoustic shadow, suggestive of a bezoar, has been reported.5,6 Moreover, the marked acoustic shadowing behind the echogenic band produced by a bezoar differs from the "dirty"  shadowing generated by ingested gas and food within the stomach.7  Since bezoars produce the same sonographic images as ectopic lithiasis, it is important to distinguish bezoar- induced obstructions from gallstone ileus.8

Bezoars have a characteristic appearance on  CT,  usually presenting as a well circumscribed in-homogeneous  intraluminal mass with a mottled gas pattern in the dilated small bowel at the site of obstruction and abrupt collapse of the lumen beyond the lesion.9,10


Therapy for any bezoar necessitates its removal and prevention of recurrence. Small bezoars may be amenable to naso-gastric lavage or suction, a clear liquid diet, and the use of prokinetic agents.11 Larger bezoars may be fragmented mechanically or with digestive enzymes.12  Endoscopic retrieval and fragmentation are frequently used for proximal bezoars whose size and density are not prohibitive; however, the procedure can be technically challenging, and fragments may migrate distally and cause small bowel obstruction.13

 A recently described technique from China incorporates a laser mini-explosive technique through an endoscope; in 100 patients, the cure rate was 100%.14 Laparotomy is reserved for bezoars that have caused perforation (7%) or hemorrhage (10%), or that are too large or obstructive to be managed less invasively.3 In patients who have undergone gastrectomy, however, the recurrence rate of phytobezoars is 13.5%, despite preventive measures.1


The author reported no conflict of interest and no funding was received on this work.


1.    Wang PY, Skarsgard ED, Baker RJ. Carpet bezoar obstruction of the small intestine. J Pediatr Surg 1996 Dec;31(12):1691-1693.
2.    Escamilla C, Robles-Campos R, Parrilla-Paricio P, Lujan-Mompean J, Liron- Ruiz R, Torralba-Martinez JA. Intestinal obstruction and bezoars. J Am Coll Surg 1994 Sep;179(3):285-288.
3.    Phillips MR, Zaheer S, Drugas GT.  Gastric trichobezoar:  case report and literature review. Mayo Clin Proc 1998 Jul;73(7):653-656. P
4.    Gelrud D, Gelrud M. Gastric bezoars. 2008 UpToDate.
5.    Ko YT, Lim JH, Lee DH, Yoon Y. Small intestinal phytobezoars: sonographic detection. Abdom Imaging 1993;18(3):271-273.
6.    Yol S, Bostanci B, Akoglu M. Laparoscopic treatment of small bowel phytobezoar  obstruction. J Laparoendosc Adv Surg Tech A 2003 Oct;13(5):325-326.
7.    Newman B, Girdany BR. Gastric  trichobezoars–sonographic and computed tomographic appearance. Pediatr Radiol 1990;20(7):526-527.
8.    Simonovsky V. Biliary ileus: preoperative  diagnosis by US—a report of two cases. Eur Radiol 1994;4:580-584
9.    Ko SF, Lee TY, Ng SH. Small bowel obstruction due to  phytobezoar: CT diagnosis. Abdom Imaging 1997 Sep-Oct;22(5):471-473.
10.  Quiroga S, Alvarez-Castells A, Sebastià MC, Pallisa E, Barluenga E. Small bowel obstruction secondary to bezoar: CT diagnosis. Abdom Imaging 1997 May-Jun;22(3):315-317.
11.  Dann DS, Rubin S, Passman H, Deosaransingh M, Bauernfeind A, Berenbom M. The successful medical management of a phytobezoar. AMA Arch Intern Med 1959 Apr;103(4):598-601.
12.  Diettrich NA, Gau FC. Postgastrectomy phytobezoars–endoscopic  diagnosis and treatment. Arch Surg 1985 Apr;120(4):432-435.
13.  Huang YC, Liu QS, Guo ZH. The use of laser ignited mini-explosive technique in treating 100 cases of gastric  bezoars. Zhonghua Nei Ke Za  Zhi  1994 Mar;33(3):172-174.
14.  Salena BJ, Hunt  RH.  Bezoars. In:  Sleisinger MH,  Fordtran  JS, editors. Gastrointestinal Disease: Pathophysiology/Diagnosis/Management. Vol 1. 5th ed. Philadelphia: Saunders; 1993. pp 758-763.