A previously healthy 72-year-old woman presented with a 2-year history of recurrent abdominal pain and bloating. The abdominal symptoms were often associated with food ingestion. No changes in defecation habits were noted. A local hospital diagnosed the patient with a mass in the small intestine and instructed regular follow-ups. The patient decided to seek further treatment at our facility and was scheduled for a small-intestine computed tomography (CT) scan with contrast.
The CT scan showed a hyperdense mass in the proximal jejunum ([Fig. 1 a]), measuring 43 × 35 mm, with neighboring intestinal dilation ([Fig. 1 b]). No thickening or enhancement of the small-intestine wall was observed.
Fig. 1 Computed tomography scan of the small intestine. a Transverse view. b Coronal view.
Owing to the location of the mass, an antegrade double-balloon endoscopy (DBE) was performed for diagnosis. The scope was advanced to the horizontal part of the duodenum, near the ligament of Treitz, where a large duodenal diverticulum was noted ([Fig. 2 a]). The cavity was obstructed by a disk-shaped, yellow bezoar, with a size of approximately 30 × 40 mm ([Fig. 2 b]). A combination of endoscopic lithotripsy and lithotomy procedures were performed, and the bezoar was successfully removed ([Fig. 3], [Video 1]).
Fig. 2 Double-balloon endoscopy of the small intestine. a A diverticulum was identified in the distal duodenum. b A large, disk-shaped bezoar was embedded in the duodenal diverticulum.
Fig. 3 Removal of the bezoar after intraluminal fragmentation.
Video 1 A double-balloon endoscopy was used for diagnosis of the unidentifiable mass in the small intestine. A large bezoar was located in a duodenal diverticulum. We attempted to remove the bezoar with a combination of lithotripsy and fragmentation.
Bezoar is a foreign body that can be found anywhere in the gastrointestinal tract and is usually composed of animal or vegetable material [1]. The condition is more common in patients with predisposed conditions, such as poor gastric motility or previous gastric surgery. The most commonly used treatment for bezoar includes a combination of endoscopic lithotripsy with basket or fragmentation with polypectomy snares. Coca-Cola administration to dissolve the bezoar has also been proven to be a cheap and safe alternative [2]. However, due to the predisposed anatomical abnormality in this specific case, combined diverticulectomy may be necessary in the future.
Endoscopy_UCTN_Code_TTT_1AP_2AD
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