Friend or foe: an unusual case of small intestinal mass

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

• References

• 1 Byrne WJ. Foreign bodies, bezoars, and caustic ingestion. Gastrointest Endosc Clin N Am 1994; 4: 99-119
• 2 Ladas SD, Kamberoglou D, Karamanolis G. et al. Systematic review: Coca-Cola can effectively dissolve gastric phytobezoars as a first-line treatment. Aliment Pharm Ther 2013; 37: 169-173