Esophageal bezoar in a patient with esophageal epiphrenic diverticulum

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.

Fig. 1 a Barium swallow esophagography showing focal outpouching, measured about 5 cm in size, at the distal third of the esophagus near the esophagogastric junction in a 57-year-old woman with dysphagia and postprandial epigastric fullness. b Esophagogastroduodenoscopy (EGD) showing dilated esophageal lumen with diverticulum formation at the lower esophagus.

Fig. 2 Blackish, 3-cm long bezoar in the diverticulum.

Esophageal diverticulum is a rare esophageal disease and can occur anywhere in the esophagus [1]. The epiphrenic diverticulum is an acquired pulsion diverticulum that occurs near the diaphragmatic hiatus [1]. 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 [2] and are typically either phytobezoars or medication bezoars [3]. 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 [4]. 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 [5].

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AF

Competing interests: None

• References

• 1 Herbella FAM, Dubecz A, Patti MG et al. Esophageal diverticula and cancer. Dis Esophagus 2012; 25: 153-158
• 2 Gupta R, Share M, Pineau BC et al. Dissolution of an esophageal bezoar withpancreatic enzyme extract. Gastrointest Endosc 2001; 54: 96-99
• 3 Kim KH, Choi SC, Seo GS et al. Esophageal bezoar in a patient with achalasia: case report and literature review. Gut Liver 2010; 4: 106-109
• 4 Lin CS, Tung CF, Peng YC et al. Successful treatment with a combination of endoscopic injection and irrigation with coca cola for gastric bezoar-induced gastric outlet obstruction. Chin Med Assoc 2008; 71: 49-52
• 5 Forget P, Hantson P. Esophageal bezoar. CJEM 2008; 10: 574