Esophageal bezoar in a patient with esophageal epiphrenic diverticulum
05 July 2013 (online)
A 57-year-old woman presented with dysphagia and postprandial epigastric fullness for about two years. Esophagogastroduodenoscopy (EGD) showed a esophageal diverticulum at the lower portion of the esophagus, and barium swallow esophagography showed a focal outpouching space (measured about 5 cm in size) at the distal third of the esophagus near the esophagogastric junction ([Fig. 1]). The patient reported having nausea and vomiting after eating in the past 2 days. She underwent another EGD, which revealed a 3-cm, blackish bezoar impacted in the esophageal diverticulum ([Fig. 2]). The bezoar was removed with a snare basket. On reviewing her history, it was found that she had been taking Pho Pu Zi (Cordia dichotoma Forst. f.) as an appetizer for a month.
Esophageal diverticulum is a rare esophageal disease and can occur anywhere in the esophagus . The epiphrenic diverticulum is an acquired pulsion diverticulum that occurs near the diaphragmatic hiatus . In about 80 % of patients it is associated with an underlying motility disorder, such as diffuse esophageal spasm, hypertensive lower esophageal sphincter (LES), and achalasia. The dysphagia is usually due to extrinsic compression by a large food-filled diverticulum or the underlying motility disorder. Esophageal bezoars are also usually associated with an underlying motility disorder. They mainly occur de novo  and are typically either phytobezoars or medication bezoars . Pho Pu Zi is a traditional Taiwanese appetizer, which may be ingested in large amounts during the harvesting season, when the sticky pulp of the fruit can form a phytobezoar . In the present case, the large epiphrenic diverticulum resulted in stagnation of the undigested food, which trigged the formation of a bezoar. The symptoms may worsen if an esophageal bezoar progressively increases in size. EGD is mandatory for diagnosis and treatment of esophageal bezoars .
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