Correspondence to: Mr P. J. Billings The first serious study of gastrointestinal bezoars was made by the Persian physician Mahamud Bin Masud in the sixteenth century. The first human bezoar, a trichobezoar, was described in 1779 by Baudamant but it was 1883 before Schonborn first removed one through a gastrostomy.Bezoars are usually formed in the stomach and may migrate into the small intestine, impacting in the terminal ileum causing intestinal obstruction. Two cases are reported of bezoars forming in intestinal diverticuli, and subsequently presenting with acute small bowel obstruction in one case and a mixed picture of perforation and obstruction in the other.
Case reportsCase I A 65-year-old lady was admitted as an emergency complaining of anorexia, vomiting, colicky abdominal pain and constipation. A barium meal was performed which showed a large, empty, diverticulum in the second part of the duodenum and dilated small bowel, but no cause for mechanical small bowel obstruction. Twelve days after admission a laparotomy was performed and a bezoar found obstructing the midileum. The bezoar was removed through an enterotomy and she made an uneventful recovery. Section of the bezoar revealed it was composed of vegetable material with a tomato skin at its centre. When last seen, 6 months after surgery, she was well and asymptomatic.Case 2 A 64-year-old man presented as an emergency with a history of 2 h severe epigastric pain and vomiting. H e had a 5-year history of postprandial epigastric pain and fullness which had been extensively investigated with two barium meals and an abdominal ultrasound; the only abnormalities were a small hiatus hernia and a radio-opaque density in the left upper quadrant. Abdominal examination showed him to have dlffuse peritonitis. Plain abdominal films showed multiple dilated loops of small bowel with fluid levels and a radio-opaque density overlying the sacrum. An erect chest X-ray showed free gas under the left hemidiaphragm.At laparotomy a bezoar was found obstructing the mid-ileum with five small areas of necrosis in the immediately proximal small bowel. There were also a number of diverticuli in the upper jejunum. The bezoar was milked back into the proximal small bowel and removed with 10cm of jejunum containing the largest 2.5 cm wide diverticulum. The small necrotic patches in the ileum were oversewn. It was found that the bezoar fitted within the diverticulum and was able to pass through the mouth of it with relative ease. Subsequent review of the patient's past barium meals showed the bezoar lying within the jejunal diverticulum in the left upper quadrant ( Figure I ) was the same opacity seen overlying the sacrum on his acute admission.He made an uneventful postoperative recovery. He was seen in out-patients 3 months later and had no further symptoms of postprandial epigastric pain and fullness.
DiscussionDiagnosis of an intestinal bezoar is not always easy, as Debakey and Ochsner' pointed out in their classic description, with most cases presenting variable symptoms of...
