Non-Surgical Resolution of Phytobezoar-Induced Bowel Obstruction Using Sodium Bicarbonate and Catheter: A Report of 2 Cases

Abstract

Case series

Patients: Male, 73-year-old Male, 74-year-old

Final Diagnosis: Ileus

Symptoms: Abdominal pain

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Objective: Unusual setting of medical care

Background

Phytobezoar-induced small bowel obstruction presents significant management challenges, particularly in patients who either decline surgery or have contraindications. These concretions, predominantly composed of persimmon tannins, account for 0.4–4.8% of intestinal obstructions in endemic regions. While surgical intervention remains standard for complete obstructions, non-surgical approaches are increasingly explored for high-risk patients. Current dissolution therapies, including the Coca-Cola protocol, often require large fluid volumes that can exacerbate the obstruction. This study evaluated the efficacy of a novel treatment using low-volume sodium bicarbonate irrigation combined with catheter decompression.

Case Reports

Two elderly men (aged 73 and 74 years) with persimmon-induced obstructions refractory to conservative treatment underwent endoscopic intestinal catheter placement. Targeted 5% sodium bicarbonate irrigation (100 mL bid) with intermittent catheter clamping was administered. Clinical progress was monitored through serial imaging and symptom assessment. Both cases achieved complete obstruction resolution without surgery. Case 1 demonstrated CT-confirmed bezoar reduction within 10 days, with spontaneous passage. Case 2 expelled a 3×7 cm bezoar after 5 days of therapy. No procedural complications or biochemical imbalances occurred. The protocol synergized bicarbonate’s mucolytic action (alkaline dissolution of phytobezoar matrices) with mechanical catheter decompression.

Conclusions

This first-reported combination therapy successfully resolved large phytobezoars (4–7 cm) within 5–10 days, establishing a safe alternative for candidates who either decline surgery or have contraindications. The method’s efficacy stems from: 1) minimized fluid volume requirements (200 mL/day vs 500–3000 mL in Coca-Cola protocols), 2) direct bezoar contact via catheter-directed delivery, and 3) dual mechanical-chemical action.

Introduction

Phytobezoars, the most common type of bezoars, account for approximately 75% of all bezoar cases [1]. Multiple studies from different continents indicate that gastric bezoars are detected in less than 0.5% of individuals undergoing esophagogastroduodenoscopy, while small intestinal bezoars account for 0.4–4.8% of all intestinal obstruction cases [2]. Predisposing conditions, including prior gastric operations, peptic ulceration, and inflammatory bowel diseases, markedly increase the risk of developing a phytobezoar. The incidence rate exhibits distinct regional and seasonal characteristics, particularly in Asian countries, which is closely associated with diet rich in tannins and pectin [2]. Studies from Japan, China, and South Korea have identified persimmons (especially unripe varieties) as the primary causative agent of phytobezoars, with patients often reporting a history of excessive persimmon consumption [3,4]. Case analyses indicate that 85.5% of phytobezoar cases occur in autumn and winter, coinciding with the harvest seasons of persimmons and hawthorns [5].

While small bowel obstruction secondary to phytobezoars often requires surgical intervention for stone extraction [5,6], numerous studies have reported successful conservative management [3,7,8]. Non-surgical treatment options include standard nasogastric decompression, intestinal obstruction catheter with/without Coca-Cola protocol, and endoscopic fragmentation techniques. Previous studies on bezoar dissolution, particularly for gastric phytobezoars, primarily employed Coca-Cola therapy [6]. However, this approach typically requires large volumes (500 mL to several liters) of Coca-Cola [9]. Infusing such volumes into an obstructed small bowel can exacerbate obstruction symptoms (abdominal distension/pain) or even cause intestinal perforation. In contrast, sodium bicarbonate demonstrates dissolution efficacy with only 250 mL daily irrigation [1], making it a safer alternative for small bowel obstruction by minimizing intestinal rupture risks. Here, we present 2 cases in which small bowel obstruction caused by phytobezoars was successfully treated non-surgically using sodium bicarbonate combined with an intestinal obstruction catheter.

Case Reports

Case 1

A 73-year-old man presented with a 3-day history of epigastric discomfort but denied obstipation. He reported being able to eat independently without dysphagia or difficulty in defecation prior to the onset of symptoms, and maintained independent daily living activities without significant mobility impairment. There was no history of severe cardiopulmonary diseases, cerebrovascular accidents, or previous abdominal surgeries. Gastroscopy at our outpatient clinic revealed a gastric bezoar. Upon further history-taking, he reported consuming a large quantity of persimmons 3 weeks prior, leading to a diagnosis of phytobezoar. The medical team advised endoscopic bezoar removal under general anesthesia, but the patient declined due to concerns about both anesthetic risks and procedural complications, requesting alternative treatment approaches instead. Hence, the gastroenterology department initiated conservative therapy with 3 liters of Coca-Cola daily for dissolution.

One week later, the patient developed sudden epigastric pain, accompanied by nausea, vomiting, and obstipation. Physical examination revealed: heart rate 76 bpm, blood pressure 111/86 mmHg, temperature 37.3°C, soft abdomen with epigastric tenderness but no rebound tenderness, normal liver and spleen palpation, and bowel sounds at 5/min. Abdominal computed tomography (CT) confirmed small bowel obstruction with bezoars, measuring 4.6 cm in maximal diameter, and the obstruction was localized to the jejunum. Laboratory findings included: white blood cell count (WBC) 6.6×10⁹/L, neutrophil percentage 77.8% (elevated), C-reactive protein (CRP) 0.6 mg/L, and albumin 46.4 g/L.

Given the patient’s advanced age, reluctance to undergo surgery, absence of severe inflammatory markers, and no signs of bowel ischemia or peritonitis, conservative management was pursued. Initial treatment included fasting, nasogastric decompression, fluid resuscitation, and nutritional support. Antispasmodics were administered for significant pain episodes. Antibiotics were withheld due to absence of evident infection. After 10 days of conservative management without clinical improvement, endoscopic placement of an intestinal decompression catheter was performed with patient consent to alleviate luminal distension and fluid accumulation.

On day 4 after catheter placement, the catheter had advanced to approximately 190 cm, suggesting contact with the obstructing bezoar. Based on prior reports [1,10] and concerns regarding alternative therapies outlined in the Introduction, 100 mL of 5% sodium bicarbonate solution was administered twice daily via the catheter for dissolution. To maximize contact time, the catheter was clamped for 2 hours after injection before resuming suction drainage. Due to the presence of undigested food debris, the catheter was flushed with 250 mL of normal saline in divided doses before each bicarbonate infusion.

After 6 days of treatment, follow-up CT demonstrated a reduction in bezoar size (Figure 1). By day 10, the patient resumed spontaneous flatus and defecation, reporting passage of the bezoar (though not retained for documentation). The catheter was removed, and the patient was discharged following gradual dietary reintroduction.

Figure 1.

Endoscopic and CT imaging findings in Case 1. (A) Gastroscopic view of the phytobezoar. (B) Initial emergency CT scan with measurements of the bezoar. (C) Follow-up abdominal CT after 6 days of sodium bicarbonate therapy, showing reduced bezoar size (measured). (D) After 10 days of treatment, the water-filled balloon tip of the intestinal obstruction catheter (white arrow) had advanced to the ascending colon.

Case 2

A 74-year-old man presented to our emergency department with a 20-day history of epigastric distension and obstipation. The patient reported independent eating ability without dysphagia or defecation difficulties prior to symptom onset, with preserved independent living capacity and no significant mobility limitations. No history of severe cardiopulmonary disease, stroke, or abdominal surgery was noted. He had received 10 days of intravenous therapy at a local clinic, without improvement. CT revealed small bowel obstruction with a bezoar in the distal ileum, measuring 6.4 cm in maximal diameter. Physical examination showed: heart rate 55 bpm, blood pressure 160/84 mmHg, temperature 36.8°C, soft abdomen with epigastric tenderness but no rebound, and bowel sounds at 6/min. Laboratory results included: WBC 7.5×10⁹/L, neutrophil percentage 64%, CRP 1.4 mg/L, albumin 41.7 g/L, and normal electrolytes. The patient reported consuming dried persimmons 2 weeks prior, supporting a phytobezoar diagnosis.

Given the large size of the bezoar, surgical intervention was recommended; however, he declined due to concerns regarding anesthetic and operative risks, opting instead for conservative management. Following the protocol in Case 1, an intestinal obstruction catheter was endoscopically placed. After 3 days, the catheter reached 245 cm. Saline irrigation and twice-daily 100 mL 5% sodium bicarbonate infusions were administered, with 2-hour clamping periods. On day 5, the patient passed a large bezoar (Figure 2), resumed normal bowel function, and was discharged after catheter removal and dietary advancement.

Figure 2.

CT imaging and photographic documentation of the bezoar in Case 2. (A) Initial emergency CT scan with measurements of the obstructing bezoar (annotated). (B) Follow-up abdominal CT after 3 days of intestinal obstruction catheter irrigation and sodium bicarbonate therapy, demonstrating bezoar size reduction (measured). (C) The expelled bezoar (approximately 3×7 cm in size) following spontaneous defecation.

Discussion

We present 2 cases of small bowel obstruction secondary to phytobezoars successfully treated with sodium bicarbonate and an intestinal obstruction catheter – the first reported use of this approach. Current management options for phytobezoars include pharmacologic dissolution (for gastric bezoars), endoscopic fragmentation/removal, and surgery [2,6].

Sodium bicarbonate, an alkaline agent, demonstrates efficacy in phytobezoar dissolution, possibly by disrupting mucoid adhesions [11]. Prior studies report successful gastric bezoar treatment using oral- or nasogastric-administered sodium bicarbonate [1,10,12–16]. Only a few studies have definitively characterized bezoar subtypes, such as phytobezoars, nutrition bezoars, and trichophytobezoars. Zheng et al [1] investigated the efficacy of sodium bicarbonate for gastric phytobezoar dissolution. Their retrospective analysis of 165 cases compared outcomes between sodium bicarbonate therapy with versus without endoscopic fragmentation, demonstrating that sodium bicarbonate monotherapy achieved satisfactory dissolution rates for phytobezoars. Moreover, this dissolution regimen requires only 250 mL of sodium bicarbonate daily, significantly less fluid volume compared to Coca-Cola therapy (minimum 500 mL, often up to several liters).

Small bowel-obstructing bezoars typically require surgery [5,6]. A prior study [17] of 40 patients with phytobezoar-induced obstruction found that 32.5% ultimately required surgery, with larger bezoar size predicting conservative failure; patients who failed conservative treatment and required surgical intervention were predominantly those with bezoars exceeding 4.0 cm in maximum diameter. These data indicated that conservative management relying solely on nasogastric or intestinal decompression catheters can have limited efficacy for larger-diameter bezoars (typically >4 cm), with an inherent risk of treatment failure. The adjunctive use of dissolution therapy could potentially improve non-operative success rates in this clinically challenging patient population. Notably, both of our cases involved bezoars >4.5 cm refractory to initial conservative measures.

For patients with contraindications or refusal of surgery, alternative conservative strategies exist. Zheng and Endo et al [3,7] described Coca-Cola combined with intestinal obstruction catheters, facilitating bezoar passage either spontaneously or via colonoscopic extraction. While Coca-Cola has demonstrated efficacy, it may incompletely dissolve diospyrobezoars [18]. Conventional Coca-Cola therapy requires large-volume infusion (500 mL to several liters) that can exacerbate bowel obstruction or precipitate perforation, while sodium bicarbonate achieved dissolution efficacy with only 250 mL daily irrigation, reducing intestinal rupture risk. Our use of sodium bicarbonate with catheter-directed irrigation offers a novel approach for refractory cases.

This non-operative approach carries several inherent limitations: requirement for serial radiographic monitoring, unpredictable time to obstruction resolution, and non-negligible failure rates necessitating emergency surgical intervention. Furthermore, the case report format precludes definitive assessment of sodium bicarbonate’s efficacy for non-diospyrobezoar phytobezoars, optimal dosing ranges, and concentration-dependent effects – critical parameters requiring systematic investigation in controlled trials.

Treatment Protocol

Catheter decompression: Gradual catheter advancement reduces intraluminal pressure (mitigating ischemia/perforation risks).

Targeted irrigation: CT-confirmed positioning enables saline clearance of debris for optimal NaHCO₃ contact.

Alkaline dissolution: sodium bicarbonate disrupts mucoid matrices, synergizing with mechanical catheter movement.

This method provides a viable alternative for patients ineligible for or declining surgery.

Conclusions

This non-surgical approach with combined sodium bicarbonate infusion and intestinal obstruction catheter placement, successfully treated 2 cases of large bezoar (up to 7 cm) within 5–10 days, demonstrating its potential as a safe alternative to surgery for patients who either decline surgery or have contraindications to operative management. Further studies are needed to validate these findings in larger patient populations.