S6181 Bezoar-Induced Small Bowel Obstruction: A Case Highlighting the Role of Imaging and Multidisciplinary Care

Introduction: Small bowel (SB) bezoars are rare, but can lead to serious complications, including ischemia and small bowel obstruction (SBO). This case highlights the importance of imaging and multidisciplinary discussion in recognizing bezoar-induced SBO. Case Description/Methods: A 68-year-old man with history of remote SBO due to jejunal diverticulitis status post SB resection presented with 5 days of generalized abdominal pain and poor oral intake. Abdominal computed tomography showed dilated, edematous SB loops. Upon admission to the surgical team, emergent intervention was deferred given benign physical exam and labs (no leukocytosis, normal lactate). The patient initially improved with intravenous fluids, nil per os (nothing by mouth), and nasogastric tube decompression. Upon diet resumption, abdominal pain recurred, along with nausea and vomiting. Repeat computed tomography revealed chronically thickened SB loops, but no evidence of ongoing obstruction. Fecal calprotectin was checked due to thickened bowel loops and was elevated (2940 μg/g). However, without other signs of inflammatory bowel disease, and concern for intermittent SBO, endoscopy was deferred. Total parenteral nutrition and intravenous antibiotics were initiated. The patient later developed acute abdominal pain, distension, nausea, and obstipation. Repeat computed tomography revealed SBO and a 3-cm bezoar in the ileum, at the transition point of the SBO. The bezoar, initially seen in the jejunum on re-review of prior imaging, had impacted the ileum, causing obstruction. It was felt the bezoar was likely intermittently obstructing, causing SBO symptoms. He underwent laparoscopic SB resection, which confirmed large SB diverticulosis and an impacted bezoar at the ileum. Post-operatively, symptoms improved, and he was later discharged. Discussion: Bezoars are conglomerates of substances (hair, plant fibers, medications, milk) that can lodge in the stomach, and less commonly cause SBO. Formation is linked to GI motility disorders, inflammatory strictures, blind loops, and SB diverticula. They can cause ischemia and obstruction. SB bezoars pose a diagnostic challenge due to variable presentation with nonspecific symptoms and difficult endoscopic visualization, making imaging crucial. Most cases require surgery, especially if the bezoar cannot be reached by endoscopy. This case highlights how the diagnosis of a bezoar-induced SBO can be delayed or missed without high clinical suspicion. It emphasizes the value of repeated imaging and collaborative decision-making among surgery, gastroenterology, and radiology.