Case Report: Successful endoscopic treatment of gastric outlet obstruction due to duodenal persimmon phytobezoar

Gastric outlet obstruction (GOO) is a clinical syndrome caused by mechanical impediment to gastric emptying. Bezoars account for < 0.4% of all GOO cases. Of these, duodenal bezoars-particularly those obstructing the narrow duodenal bulb-are exceptionally rare. Duodenal persimmon phytobezoar-induced gastric outlet obstruction (GOO) is particularly distinctive in elderly patients, with only a handful of relevant case reports documented in the literature. We present the case of successful endoscopic fragmentation in an 88-year-old female with GOO caused by a persimmon bezoar located in the duodenal bulb. Abdominal CT and upper endoscopy showed a giant bezoar nearly completely obstructing the duodenal lumen. After 3 days of failed chemical dissolution with sodium bicarbonate solution and Coca-Cola, she underwent two endoscopic fragmentations using simple and readily-available endoscopic instruments, such as rat-tooth forceps, snares, and baskets. More than ten persimmon seeds were extracted during the procedure. Upper endoscopy was repeated and revealed that the bezoar had disappeared, with two necrotic pressure ulcers noted in the duodenal bulb. The patient recovered well and was discharged 4 days following the second endoscopic fragmentation. The patient remained asymptomatic during 3 months of follow-up. Phytobezoars are rarely found in the duodenum, as in the case of this patient. This case highlights the feasibility and efficacy of endoscopic therapy for duodenal bezoar-induced GOO, especially in elderly patients. Furthermore, the use of simple, readily-available endoscopic instruments (rat-tooth forceps, snares, and baskets) makes this approach particularly suitable for use in resource-limited settings.