The origin of word "bezoar" derives either from the Arabic term "badzehr" or the Persian word "padzahr," both of which denote counterpoison or antidote. This word was applied to a greenish, hard concretion found in the fourth stomach of the Syrian goat. The stone was felt to prevent poisoning and came to Europe as the bezoar stone, which was highly prized for its medicinal properties [12, 13].
In our patient, abnormal mastication habits as well as a jejunal diverticulum were the precipitating factors for phytobezoar formation that led to small-bowel obstruction. Although the commonest cause is previous gastric surgery, in our patient there was no such history. Phytobezoars usually occur as single entities, but multiple phytobezoars have been reported in the stomach in 17% of patients and in the intestine in 4% of patients [3, 14].
Krausz et al. [15] reported a huge increase in the incidence of phytobezoar obstruction in Israel, which was related to the increasing availability and popularity of the persimmon fruit. In Hong Kong, the mid-autumn festival is celebrated in October. During this festival, it is a traditional to eat persimmon fruit. Chisholm et al. [16] reported that two-thirds of the patients in their series presented around this festival time.
Common causes of small-bowel obstruction are adhesions, strangulated hernia, malignancy, volvulus, and inflammatory bowel disease. Phytobezoars are rare, accounting for only 0.4% to 4% of all intestinal obstruction. No particular age or sex prevalence has been observed [17]. Primary small-bowel bezoars almost always present as intestinal obstructions.
A number of diagnostic modalities have been used for the detection of abdominal bezoars. Rippolés et al. [18] reported a phytobezoar detection rate of 88% by ultrasound in patients with small-bowel obstruction. The main limitation of ultrasound is that it is operator-dependent and may be unreliable, as seen in our case. Computed tomography shows the phytobezoars as a mass, a filling defect, or a fecal ball sign [19], which is considered an accurate diagnostic sign in the preoperative diagnosis of phytobezoar.
Small-bowel bezoars are usually treated surgically. It is mandatory to explore the whole gastrointestinal tract to avoid synchronous bezoars and the recurrence of intestinal obstruction due to retained bezoars. Other described treatment options include enzymatic breakdown and endoscopic fragmentation for gastric bezoars [1, 20].
In summary, we have described a case of an elderly man with a small-bowel obstruction due to a phytobezoar complicating a jejunal diverticulum. He had a combination of two rarities, that is, jejunal diverticulum and a phytobezoar as a cause of small-bowel obstruction.
A search of the surgical literature revealed only one case of an obstructing phytobezoar arising from a proximal jejunal diverticulum [21].