Duodenal obstruction following acute pancreatitis caused by a large duodenal diverticular bezoar

Abstract

Bezoars are concretions of indigestible materials in the gastrointestinal tract. It generally develops in patients with previous gastric surgery or patients with delayed gastric emptying. Cases of periampullary duodenal divericular bezoar are rare. Clinical manifestations by a bezoar vary from no symptom to acute abdominal syndrome depending on the location of the bezoar. Biliary obstruction or acute pancreatitis caused by a bezoar has been rarely reported. Small bowel obstruction by a bezoar is also rare, but it is a complication that requires surgery. This is a case of acute pancreatitis and subsequent duodenal obstruction caused by a large duodenal bezoar migrating from a periampullary diverticulum to the duodenal lumen, which mimicked pancreatic abscess or microperforation on abdominal computerized tomography. The patient underwent surgical removal of the bezoar and recovered completely.

Keywords: Bezoar; Diverticulum; Duodenal obstruction; Pancreatitis.

Figure 1

Abdominal computed tomography findings. A: The pancreas head showed swelling with irregular contour of the pancreatic margin and mild peripancreatic infiltration; B: There is a 5 cm size subtle rim enhancing mass with air bubbles, indicating acute diverticulitis in the second duodenal portion or air forming abscess of the pancreatic head; C: After nine days, a few extraluminal air bubbles (arrow) suspicious for microperforation were found.

Figure 2

Endoscopic findings. A: There is a huge luminal obstructing bezoar near the duodenal diverticulum; B: The bezoar was too large to be captured and removed by an endoscopic basket or net.

Figure 3

Surgical findings. A: Obstructed duodenum with impacted huge bezoar (arrow); B: Surgical specimen of the divided bezoar, 5 cm long, 2.5 cm in diameter.

Figure 4

Upper gastrointestinal series show two periampullary diverticula (arrows) in the second duodenal portion.