CASE REPORT Hellenic Journal of Surgery (2019) 91:1, 44-48

Small Bowel Obstruction Due to Phytobezoars:

Report of Four Cases and Literature Review
Paschos KA, Triantaphilidis A, Chatzipourganis K, Paraskeva Aikaterini, Gravalidou Ioanna, Chatzigeorgiadis A

Abstract
Bezoars are concretions of indigestible foreign materials that develop within the gastrointestinal (GI) tract. A variety
of materials received orally may form these masses. According to their composition, bezoars are classified as phyto-
bezoars, which are the most frequent, trichobezoars, pharmacobezoars, lactobezoars, and other more rare entities.
They are formed most frequently in the stomach and they may trigger serious symptoms, including dysphagia, ab-
dominal pain, hematemesis, and intestinal obstruction or perforation. Contrast-enhanced computerized tomography
(CT), in conjunction with GI endoscopy, has contributed substantially to the prompt and accurate diagnosis of these
masses. Endoscopy also offers reliable therapeutic options, either through chemical disintegration of the bezoars or
mechanical fragmentation and removal. The more serious cases of intestinal bezoars are usually treated surgically,
either laparoscopically or via traditional laparotomy. This series describes four cases of intestinal phytobezoars that
caused small bowel obstruction, and, in one case perforation, and were all treated surgically. Current advances in
the diagnosis and treatment of bezoars are discussed and compared with the well-established methods.

Key words: Bezoar; ileus; intestinal obstruction; phytobezoar; small intestine; stomach

Bezoars are constituted of large conglomerates of poorly-
or non-digested material, formed within the gastrointestinal
(GI) tract. They are named according to their composition,
for example phytobezoar, from the Greek word phyto
(φυτό)=plant, which are composed of vegetable and/or
fruit matter, such as celery, prune, grape skin, orange,
persimmon, etc., and are the most common. Other types
are trichobezoars, from the Greek word tricha (τρίχα)=hair
which contain hair, lactobezoars, which are formed from
concentrated infant milk formula, pharmacobezoars, from
the Greek pharmaco (φάρμακο)=medication, from medica-
tions including kayexalate, antacids, cholestyramine, etc.,
and other less frequent entities such as paperbezoars [1-3].
The stomach is the most common site of bezoar formation.
The clinical manifestations range from no symptoms at all
to acute abdomen, depending on the location of the bezoar.
Small bowel obstruction secondary to bezoars is rare, ac-
counting for 0.4-4.8% of all causes of obstruction [4].
The association between gastrectomy and phytobezoar
formation is widely accepted. While the pylorus of a normal
stomach impedes the passage of vegetable and fruit fibers
before they are hydrolyzed, gastric surgery disturbs gastric
Department of Surgery, Drama General Hospital, Drama, Greece
Corresponding author: Paschos A Konstantinos MD, MSc, PhD
Consultant Surgeon, Department of General Surgery, General Hospital
of Drama, Terma Ippokratous St., 66100, Drama, Greece
Tel: +30-2521-350413, e-mail: kostaspaschos@yahoo.gr
Received Feb 25, 2019; Accepted Mar 12, 2019
motility and decreases acidity within the stomach, lead-
ing to bezoar formation and transfer to the small bowel.
This abnormal process may give rise to symptoms and/or
conditions such as ileus and acute abdomen [5,4]. Other
predisposing factors for phytobezoar formation may be
mastication abnormalities, excessive high-fiber food con-
sumption, long-term antacid treatment, diabetic neuropathy,
hypothyroidism and myotonic dystrophy. Primary intestinal
bezoars are extremely rare and are usually associated with
intestinal tumors, diverticula or strictures, disorders that
cause or facilitate the entrapment of food material in the
small bowel [6,5].
This case series presents the recent experience of a
regional Greek hospital regarding the diagnosis and treat-
ment of small bowel obstruction caused by phytobezoars.
Presentation of cases
Case 1
A 68-year-old male presented at the emergency depart-
ment (ED) with severe diffuse abdominal pain of sudden
onset, nausea and vomiting. His medical history included
partial gastrectomy for benign gastric ulcer 4 decades
earlier. On physical examination the patient had increased
bowel sounds and abdominal discomfort, mainly epiga-
stric, without tenderness. No palpable mass or blood was
detected on rectal examination. His blood pressure was
140/85mmHg, his pulse rate was 87/minute and he was
afebrile. Initial laboratory data showed mild neutrophilic

Hellenic Journal of Surgery 91


leukocytosis; white blood cell count (WBC) 12.52k/μl, neu-
trophils 76.2%, hemoglobin (Hb) 13.8g/dl and urea 47mg/
dl. An abdominal X-ray was consistent with gas ileus and
a nasogastric tube was inserted.
Although his clinical status showed temporary im-
provement, the intestinal distention recurred 3 days later.
Abdominal helical computed tomography (CT) revealed
dilated jejunal and ileal loops up to the ileocecal valve and
a heterogeneous mass with a honeycomb configuration
containing pockets of air in the terminal ileum (Figure 1A).
Laparotomy revealed a phytobezoar (15x5cm), 30-40 cm
proximal to the ileocecal valve, which was removed via
enterotomy (Figure 1B). The patient had an uneventful
recovery and was discharged on the 7th postoperative day
with counseling on dietary habits and proper mastication
to avoid similar problems in the future.
Case 2
A 72-year-old female was brought to the ED with
abdominal pain, severe constipation and no flatus dis-
charge. Her medical history included an abdominop-
erineal resection 4 years earlier, with a postoperative
midline hernia. Physical examination identified diffuse
abdominal sensitivity on deep palpitation, and diminished
bowel movements on abdominal auscultation. Her blood
pressure was 155/85mmHg and her pulse 65/minute. Her
blood tests were unremarkable, apart from anemia, with
Hb 10.3g/dl. Abdominal helical CT demonstrated small
bowel obstruction with perforation and the presence of a
large intraluminal mass with a honeycomb pattern, con-
taining pockets of air (Figure 2A). Following resuscitation,
exploratory laparotomy was performed which revealed a
terminal ileum perforation, along with a large phytobezoar
(75x8cm) (Figure 2B). The phytobezoar was removed and
intestinal resection was performed at the site of perfora-
1A
Figure 1. A. Contrast-enhanced computerized tomography (CT) showing a phytobezoar (white arrow shows typical mottled appearance) in the
ileum causing intestinal obstruction; B. Intraoperative image of enterotomy performed via laparotomy to remove the ileal phytobezoar (15x5cm).
Hellenic Journal of Surgery 91
Small Bowel Obstruction Due to Phytobezoars 45
tion, with end-to-end anastomosis. The postoperative
course was uneventful and the patient was discharged
home the 11th day.
Case 3
A 51-year-old man attended the ED with a two-day
history of epigastric pain and vomiting. His medical history
included partial gastrectomy because of a benign gastroduo-
denal ulcer 3 decades earlier, appendicectomy and HBSAg
positive for Hepatitis B. On physical examination he had
temperature 37.2 C°, blood pressure 140/80 mmHg and
pulse 100/min. His blood tests were within the normal range
(WBC 8.18k/μl, neutrophils 78.9%, Hb 14.2g/dl), and liver
and renal biochemistry unremarkable. Abdominal helical
CT scan showed a heterogeneous mass in the terminal ileum
with intestinal distention proximal to the mass.
Exploratory laparotomy revealed a phytobezoar (8x3cm)
that was removed through an enterotomy. The patient reco-
vered well and was discharged on the 6th postoperative day.
Case 4
A 62-year-old man was admitted to the surgical depart-
ment, presenting with repetitive vomiting for 2 days, diffuse
abdominal pain and distention. He was a heavy drinker,
and had a history of surgical vagotomy and pyloroplasty
for gastric perforation 40 years earlier. In addition, he had
surgery for ileus due to intestinal phytobezoar 20 years ago.
He also had a coronary by-pass operation in the recent past
and was taking acetylsalicylic acid (100mg/day). Physical
examination revealed a tender distended abdomen, sensitive
to deep palpitation and an empty rectum. An abdominal
X-ray showed distended intestinal loops with gas, and a
nasogastric tube was therefore inserted. Helical CT scan
revealed intestinal ileus and a mass in the ileum with a
mottled air pattern (Figure 3). Exploratory laparotomy
1B
46 Paschos KA, et al

2A 2B
Figure 2. Intestinal phytobezoar with perforation in a 72-year-old female: A. Contrast-enhanced computerized tomography (CT) showing
the phytobezoar. B. Intraoperative image showing the phytobezoar (75x8cm).

revealed multiple intestinal symphyses attributed to the

previous abdominal operations, and a phytobezoar in the
ileum (11cmx4cm), which was removed through an ileal
enterotomy.
Postoperatively the patient developed a superficial surgi-
cal site infection and was discharged from the hospital on
the 15th day after surgery.

Discussion
The word bezoar originates either from the Arabic term
“badzehr” or possibly the Persian word “padzahr”, both
meaning to expel poison, or counterpoison or antidote.
These words were used to describe a greenish, hard con-
cretion found in the animal stomach, which was formerly
considered a useful medication, sometimes with magical
properties. In the mid-1890s, Quain, an Irish surgeon
and anatomist at the university of London, reported a
mass in the stomach, found on autopsy, which he called
a “bezoar” [7,5].
Bezoars are recognized as infrequent entities with phy-
tobezoars being the most common type. In 1987, Ahn and
colleagues reported 14 cases of bezoar in 3,247 esophago-
duodenoscopies (0.43%) performed in a 7-year period [8].
More recently, Mihai and colleagues reported 34 cases of
phytobezoar of 49 bezoars found over 20 years, with a lower
overall incidence (0.068%) [9].
Although bezoars are developed primarily in the sto-
mach, they may migrate into the small bowel and cause
acute or incomplete obstruction. Kirstein and colleagues
reported a series of 65 patients in 6 years who were operated
on laparoscopically for intestinal obstruction. Among them
three cases caused by bezoars (4.6%) represented the fifth
causative factor [10]. Concurrently, Yakan and colleagues
reported a series of 432 patients in 10 years who were treated
Figure 3. Intestinal phytobezoar in a 62-year-old male: Contrast-
enhanced computerized tomography (CT) showing the phytobezoar
(11x4cm) in the ileum causing intestinal obstruction (white arrow
shows typical mottled appearance).
surgically. Among them forteen cases were attributed to
phytobezoars (3.2%) [11].
Gastric surgery (vagotomy, pyloroplasty, antrectomy,
gastrojejunostomy) is a main predisposing factor for bezoar
formation, and had been performed in 3 of our 4 cases. In
the published series, 20-93% of patients who presented
bezoars had undergone some type of gastric surgery. It has
been reported that 5-12% of patients who had undergone
gastric surgery subsequently formed one or more bezoars
in their GI tract [12,4].
The clinical presentation of bezoars varies. They may
develop and remain asymptomatic or cause only transient
subacute symptoms, or they may give rise to multiple
abnormal symptoms and signs originating from the ali-
mentary tract. Typically, they present with abdominal pain
or discomfort, anorexia and nausea [13]. Bezoars can in-

Hellenic Journal of Surgery 91


crease the intraluminal pressure, they may cause ulcers as
well as mucosal necrosis. More rarely, bezoars may cause
complete intestinal obstruction or perforation, which are
associated with serious symptoms, including severe pain,
abdominal rigidity, hypotension, mental disorientation
and shock [14,15].
Recent advances in imaging methods have facilitated
the diagnosis of bezoars and the complications that they
may trigger. Upper GI bezoars can be localized with the use
of esophago-gastroduodenoscopy, and this technique may
also offer therapeutic options. Usually, a bezoar appears
as a single mass in the stomach and the color may vary,
depending on their composition and chemical synthesis
(black, green, blue). Very rarely, they may be multiple or
may become impacted in the esophagus or duodenum [1].
In the case that they are localized in the ileum, which
may cause ileus, radiological imaging plays a critical role in
the diagnostic process. Plain X-ray may show air-fluid levels,
indicating intestinal obstruction, but not differentiating its
cause. Ultrasonography (U/S) can detect bezoar-induced ileus
(sensitivity 88%-93%), as these masses create hyperechoic
acoustic shading, but U/S is an operator-dependent diagnostic
technique, and abdominal distention with multiple air-fluid
levels may block the view of the bezoar on U/S [16,17].
Barium studies may show the localization of bezoars
and can differentiate diverticular disease, intraluminal
adenomas and malignancies from bezoars, but are not
indicated in emergency investigations and may exacerbate
peritonitis in the presence of intestinal perforation [16].
It is generally accepted that contrast-enhanced CT is the
preferred imaging method for the diagnosis of bezoars,
with sensitivity of up to 90% and specificity of up to 60%.
Regarding phytobezoars, CT presents round or oviform
masses with air bubbles and a honeycomb configuration.
A round, mottled intraluminal mass (similar to feces in
appearance) in the area of obstruction, with dilated intes-
tinal loops proximally and collapsed intestine distally is a
pathognomonic CT sign for bezoar-induced ileus [18-20].
The options for the management of bezoars depend on
a variety of factors, including the location, size and chemi-
cal synthesis, the symptoms and signs they cause, and their
complications. As the most common location of bezoars is
the stomach, the use of gastroduodenoscopy is the primary
therapeutic approach. It may be used to achieve chemical
dissolution, using saline solution, hydrochloric acid, sodium
bicarbonate, carbohydrated fluids, and/or enzymatic agents
(e.g., cellulase), depending on the composition of the bezoar
[21-24]. Endoscopy may also be used to achieve mechanical
disintegration of the bezoars located in the upper GI, using
a mechanical lithotripter, electrosurgical knives, laser or
argon plasma devices, along with Dormia baskets or snares
for extraction [25-27].
Hellenic Journal of Surgery 91
Small Bowel Obstruction Due to Phytobezoars 47
In the event that the aforementioned approaches are
unsuccessful, or when the bezoars are located in the small
intestine or cause ileus, intestinal ischemia or perforation,
surgical intervention is mandatory. Bezoars that cause
obstruction are usually located in the distal part of the
small bowel, less than 90cm proximal to the ileocecal
valve, due to the lower motility of this intestinal segment,
its smaller diameter, and the increased water absorption
that occurs at the distal end of the ileum. When surgi-
cal treatment is chosen, two different approaches are
available, laparoscopic abdominal exploration or lapa-
rotomy. Both approaches allow enterotomy and removal
of the mass [28-30]. The “milking” technique, to move
the bezoar proximally towards the stomach or distally
through the ileocecal valve, has been described in the
case of laparotomy, although with many objections, as
these maneuvers may cause laceration of the intestinal
serosa or mesentery and intraluminal bleeding [31,11].
Although open laparotomy is well established for bezoar
treatment, laparoscopic surgery is being used increasingly
over the last decade, mostly performed in appropriately
equipped and well-staffed medical centers [32,33]. Fur-
ther research is needed to clarify the etiology and chemical
synthesis of bezoars. Taking into consideration the human
aging that is occurring globally, mainly in the developed
countries, bezoars are being detected increasingly com-
monly. Past gastric surgery, medications, peptic abnormali-
ties and mastication problems that affect older people act
synergistically in bezoar formation. Modern endoscopy
offers reliable diagnostic and therapeutic options, contrast-
enhanced CT constitutes a reliable diagnostic technique,
and surgery continues to be the preferred treatment in
complicated cases.
Conflict of Interest: The authors declare that they have no
conflict of interest
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