title: Small-bowel obstruction secondary to bezoar impaction: a diagnostic dilemma.
abstract: BACKGROUND
  Gastrointestinal bezoar (GIB) is uncommon and is reported to occur in 4% of all admissions for small-bowel obstruction (SBO). Because of a lack of diagnostic features, it is often associated with a delay in treatment, with increased morbidity. In this article, we report our experience with managing bezoar-induced SBO and the role of early computed tomography (CT) imaging in establishing the diagnosis.
  
  
  METHODS
  We retrospectively reviewed all cases of bezoar-induced SBO treated in our unit between 1999 and 2005.
  
  
  RESULTS
  There were 43 patients, of whom 2 had a recurrence, giving a total of 45 episodes. The frequency of bezoar in our patients presenting with SBO was 4.3%. All patients were of Asian origin: 41 Chinese, 1 Indian, and 1 Malay. Twenty-eight (65%) patients had previous abdominal surgery of which 26 were gastric surgery. Thirty-eight (88%) patients were edentulous. Forty-one (91%) underwent serial abdominal radiography, whereas only 4 patients (9%) had either CT imaging or contrast study alone. Only 11 (24%) cases had a correct diagnosis of bezoar impaction made preoperatively by CT imaging. The diagnostic accuracy of CT imaging in our series was 65%, with six cases of misdiagnosis. Overall, CT led to a change in management of 76% (13 in 17). The median time to surgery from admission was 2 (0-10) days. There were 2 cases of ischemic bowel that necessitated bowel resection. The median length of hospital stay was 11 (5-100) days. Ten patients (22%) had postoperative complications, and there was one death.
  
  
  CONCLUSIONS
  Bezoar-induced SBO is uncommon and remains a diagnostic and management challenge. It should be suspected in patients with an increased risk of formation of GIB, such as previous gastric surgery, poor dentition, and a suggestive history of increased fibre intake. We advocate that CT imaging be performed early in these at-risk patients and in patients presenting with SBO with or without a history of abdominal surgery in order to reduce unnecessary delays before appropriate surgical intervention.
authors.affiliation: General Surgery, Tan Tock Seng Hospital, Singapore, 308433, Singapore. thomas_ho@ttsh.com.sg
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Ho
authors.forename: Dean C
authors.initials: DC
authors.lastname: Koh
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001630:Bezoars / Q000150:complications* / Q000175:diagnosis* / Q000601:surgery; D016009:Chi-Square Distribution; D003937:Diagnosis, Differential; D003952:Diagnostic Imaging; D005260:Female; D006801:Humans; D007415:Intestinal Obstruction / Q000175:diagnosis* / Q000209:etiology* / Q000601:surgery; D007421:Intestine, Small; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D016896:Treatment Outcome