Intermittent small-bowel obstruction due to a mobile bezoar diagnosed with single-balloon enteroscopy.

tes mellitus had been having intermittent, cramping abdominal pain for 2months. He also had abdominal distension, which tended to improvespontaneously. Physical examination of the abdomen showedmild distension with decreasing bowel sounds. A small-bowel barium study showed delayed passage of the contrast medium and a dilated small bowel but nomechanical obstruction. Abdominal computed tomography (CT) also showed dilatation of the small intestine with fecal material in the ileum (●" Fig. 1). Retrograde singleballoon enteroscopy revealed a mobile bezoar, about 4–5 cm in size, along with several ulcers in the ileum (100 cm proximal to the ileocecal valve) (●" Fig. 2). The bezoar was fragmented with forceps and snare (●" Fig. 3). The abdominal pain reduced and the patient started to feed well. Unfortunately, after 1weekhehadabdominal pain again, and surgery was carried out to remove the bezoar from the ileum. Gastrointestinal bezoars are rare, causing 4% of all small-bowel obstruction (SBO). The time period between development of symptoms to admission has been usually reported to be 2 days and the interval between admission to operation is also usually 2 days [1]. It is interesting that in our patient the bezoar presented with intermittent abdominal pain only, that is, without obstruction. This may be because the bezoar was not large enough to obstruct the lumen, but as it was mobile, it rolled around in the lumen. Preoperative diagnosis of bezoars by CT is difficult; the findings have included a well-defined, ovoid-shaped, intraluminal mass containing mottled gas, and they have also been referred to as small-bowel fecoliths [2,3]. Nevertheless, not all small-bowel fecoliths are bezoars. In SBO, in 55.9% patients reported as having small-bowel fecoliths none had an impacted bezoar [2,4]. Balloon-assisted enteroscopy, including singleand double-balloon enteroscopy, is an excellent tool for evaluation of the small intestine. It can be used to fragment bezoars and resolve any obstruction [3]. In our case, although the bezoar was fragmented, it re-formed again 1 week later. Thus, management of a bezoar by fragmentation may not be enough, and it should be removed as soon as possible.