Coca-Cola^® dissolution therapy for a bezoar impacted in the second portion of the duodenum: a case report

Abstract

Introduction:

A bezoar is an insoluble mass formed in the stomach due to the degeneration of food or foreign substances by gastric juice and mucus. Tannin-rich persimmons are known to form bezoars, which can frequently cause gastric ulcers and intestinal obstructions. We report a case in which a bezoar impacting the second portion of the duodenum was successfully moved to the jejunum using Coca-Cola dissolution therapy, thus avoiding extensive surgical procedures such as pancreaticoduodenectomy.

Case presentation:

A 76-year-old man presented at our hospital with vomiting. CT revealed a bezoar and intestinal obstruction in the second portion of the duodenum. Upper gastrointestinal endoscopy confirmed bezoar-induced obstruction. A conservative treatment with nasogastric decompression and Coca-Cola infusion was initiated. Although the first course was ineffective, repeated administration eventually moved the bezoar distally, and laparoscopic partial jejunal resection was performed. The postoperative recovery was favorable.

Discussion:

Complete endoscopic dissolution or removal of bezoars is often challenging, and surgical intervention is required in cases of persistent impaction. Duodenal impaction, particularly in the second portion, may necessitate pancreaticoduodenectomy, a highly invasive procedure. In the present case, a repeated Coca-Cola dissolution therapy facilitated distal migration of the impacted bezoar, enabling a less invasive surgical approach and potentially reducing operative morbidity.

Conclusion:

We report a rare case in which a bezoar impacted in the second portion of the duodenum was successfully managed with a repeated Coca-Cola dissolution therapy, resulting in distal migration to the jejunum and avoidance of pancreaticoduodenectomy. This case highlights the potential role of conservative dissolution therapy as a bridge strategy to reduce surgical invasiveness in carefully selected patients.

Introduction

A bezoar is an insoluble mass formed by food residue or foreign material that aggregates in the stomach and may cause intestinal obstruction or ulceration. Diospyrobezoars formed from persimmons contain tannins, are particularly difficult to treat, and often resist endoscopic removal or chemical dissolution therapy[1]. Coca-Cola dissolution therapy has been reported to be a noninvasive method in this regard. However, its effectiveness is limited; in some cases, bezoar migration can cause intestinal obstruction[2]. If a bezoar becomes impacted in the duodenum, a pancreaticoduodenectomy, which is a highly invasive procedure, may be required. In the present case, a bezoar impacted in the second portion of the duodenum was moved to the jejunum through a repeated Coca-Cola therapy, which successfully avoided extensive surgery. This manuscript was prepared following the SCARE Guidelines 2025 criteria[3].

HIGHLIGHTS

• Duodenal bezoars can be difficult to remove and may require a highly invasive surgery.

• Such bezoars can be moved by Coca-Cola dissolution therapy.

• We successfully moved an impacted duodenal bezoar with this therapy in our patient.

• Coca-Cola dissolution can be a minimally invasive, conservative treatment option.

Case presentation

A 76-year-old man presented to the emergency department with a several-month history of recurrent vomiting and epigastric discomfort. He had undergone laparoscopic partial gastrectomy for a gastric gastrointestinal stromal tumor located in the middle body of the stomach 10 years earlier, with no evidence of recurrence. Previously, he had been diagnosed with mild dementia 5 years but remained independent in activities of daily living; however, it was difficult for him to appropriately manage dietary habits. He also reported frequent consumption of persimmons.

Abdominal CT revealed a 70 mm bezoar in the second portion of the duodenum, causing a bowel obstruction (Fig. 1). Upper gastrointestinal endoscopy confirmed the presence of the bezoar (Fig. 2A). An upper gastrointestinal contrast study showed no passage of the contrast medium distal to the bezoar, leading to a diagnosis of bezoar-induced duodenal obstruction (Fig. 2B).

Figure 1.

Abdominal CT on admission. (A) Axial view showing a 70-mm bezoar impacted in the second portion of the duodenum (arrow). (B) Coronal view confirming the bezoar in the same location (arrow).

Figure 2.

(A) Upper gastrointestinal endoscopy. Endoscopic image showing a bezoar impacted in the second portion of the duodenum. (B) Upper gastrointestinal contrast study. Upper gastrointestinal contrast study showing a bezoar impacted in the second portion of the duodenum. No contrast passage is observed distal to the bezoar, indicating obstruction of the intestinal lumen (arrow).

Endoscopic removal was deemed difficult, and given the proximity of the bezoar to the ampulla of Vater, extensive surgery, such as pancreaticoduodenectomy, was considered high-risk. Therefore, we opted for the Coca-Cola dissolution therapy to promote distal migration of the bezoar and planned a less invasive surgical approach.

A nasogastric tube was placed. Coca-Cola (250 ml per administration, twice daily) was infused via the tube for 5 days starting on hospital day 2. The patient was kept nil per os during this period, and nutritional support was provided with total parenteral nutrition and intravenous hydration.

A CT after the initial course showed migration of the bezoar to the proximal jejunum; however, proximal dilatation persisted (Fig. 3). On day 20, CT showed further movement of the bezoar to the distal jejunum. As additional distal migration was desired, Coca-Cola infusion (using the same regimen) was repeated for 5 more days starting on day 22. Posttreatment CT (Fig. 4) and endoscopy confirmed migration to the distal jejunum.

Figure 3.

Abdominal CT after the initial Coca-Cola therapy. (A) Axial view showing migration of the bezoar to the proximal jejunum with persistent proximal dilatation (arrow). (B) Coronal view confirming the bezoar in the proximal jejunum with upstream dilatation (arrow).

Figure 4.

Follow-up abdominal CT after repeated Coca-Cola therapy. (A) Axial view showing distal migration of the bezoar into the jejunum (arrow). (B) Coronal view demonstrating the bezoar in the jejunum (arrow).

Partial small bowel resection was performed laparoscopically using a mini-laparotomy. The jejunum was exteriorized, and the segment containing the impacted bezoar showed marked thinning; therefore, segmental small bowel resection was performed. Component analysis of the bezoar was attempted but proved inconclusive. The patient’s postoperative course was uneventful (Fig. 5).

Figure 5.

Resected specimen. Gross appearance of the resected bezoar retrieved during laparoscopic partial small bowel resection.

Discussion

In a 2013 systematic review of 46 cases (2002–2012), Coca-Cola achieved an overall success rate of 91.3%; the success rate was approximately 50% with Coca-Cola alone and >90% when combined with endoscopic techniques[2]. The proposed mechanisms include the acidification of gastric contents, the mechanical effects of CO₂ bubbles, and contributions on the part of phosphoric acid^[1,2^]. Favorable outcomes with Coca-Cola therapy for phytobezoars have been reported in several case reports and small case series[4]. In contrast, Ugenti et al[5] achieved successful resolution through endoscopic fragmentation without the use of Coca-Cola. A comparison with previous reports is summarized in Table 1. These findings suggest that although Coca-Cola can be useful in selected cases, its efficacy is not universal. For enteral bezoars, the Zurich group demonstrated that 8.4% sodium bicarbonate effectively dissolved concretions in vitro, whereas Coca-Cola had no in vitro effect[6].

Table 1.

Comparison with previous reports.

Ref	Author	Age/sex	Bezoar location	Treatment	Outcome/note
4	Ota et al[4]	77/M	Stomach (gastric outlet obstruction)	Coca-Cola administration + endoscopic injection + crushing/removal	Non-surgical, resolved
5	Ugenti et a[5]	76/M	Stomach	Endoscopic mechanical fragmentation/removal (no Coca-Cola)	Non-surgical, resolved
6	Morell et al[6]	Case series (69/M; 59/F; 80/M)	Esophagus (nutrition bezoars)	8.4% sodium bicarbonate dissolution (Coca-Cola ineffective in vitro)	Non-surgical, resolved
7	Lu & Zhang[7]	88/F	Stomach (GOO during therapy)	Coca-Cola therapy; endoscopic management of complication	Non-surgical, resolved
8	Wang et al[8]	65/F	Stomach → small bowel (migration)	Dissolution → migration; endoscopic basket/net retrieval	Non-surgical, resolved; pancreatitis + SBO occurred
9	Oh et al[9]	Series (n = 20)	Small bowel	Predominantly surgery (enterotomy)	Predominantly surgical
10	Endo et al[10]	82/M	Small bowel (obstructive bezoars)	Coca-Cola Zero via long intestinal tube + endoscopic manipulation	Non-surgical, resolved
11	Huang et al[11]	59/F	Small intestine (elderly diabetic)	Surgery (enterotomy + removal)	Surgical
12	Namikawa et al[12]	NA	Stomach (multiple diospyrobezoars)	Laparoscopic removal	Surgical
—	Present case, 2025	76/M	Duodenum (2nd portion) → jejunum (migration)	Coca-Cola via nasogastric infusion (two courses) → migration; endoscopic confirmation; limited jejunal resection	Limited surgery; PD avoided

GOO, gastric outlet obstruction; NA, not available; PD, pancreaticoduodenectomy; SBO, small-bowel obstruction.

However, the optimal indications and safety profile of conservative treatment remain unclear. Lu and Zhang[7] reported a case in which a gastric bezoar migrated to the pylorus, causing gastric outlet obstruction. Similarly, Wang et al[8] described a case in which a bezoar migrated to the small intestine after dissolution therapy, leading to intestinal obstruction and acute pancreatitis. According to Oh et al[9], bezoars account for approximately 4% of small bowel obstructions, and reviews report a range of 0.4–4%, warranting vigilance regarding complications such as perforation. In response to such complications, Endo et al[10] demonstrated improved outcomes by administering Coca-Cola Zero via a long intestinal tube with endoscopic manipulation in incarcerated patients. However, Huang[11] and Namikawa[12] highlighted difficult cases in which conservative therapy failed and surgical removal was ultimately required.

This case is notable for its application of Coca-Cola therapy from the perspective of the “release of incarceration” and the “distal migration of the lesion.” It may serve as an example of a stepwise treatment strategy integrating medical and surgical management and may inform future therapeutic decision-making.

The causal relationship between Coca-Cola administration and distal migration of the bezoar cannot be definitively established, as physiological digestion and intestinal peristalsis may also have contributed. Therefore, the observed migration should be interpreted as an association rather than a proven effect of the intervention.

Although the time to final resolution was relatively prolonged, this strategy was intentionally selected with serial imaging and careful clinical observation to avoid high-risk extensive surgery, and the patient remained clinically stable throughout conservative management with adequate nutritional support.

In the present case, repeated nasogastric administration of Coca-Cola facilitated softening and distal migration of a persimmon bezoar incarcerated in the second portion of the duodenum. This allowed conversion from a potentially extensive procedure, such as pancreaticoduodenectomy, to a limited jejunal resection. Rather than serving solely as a definitive therapy, dissolution treatment functioned as a stepwise strategy that reduced surgical invasiveness while maintaining clinical safety under close monitoring.

Given the variability in reported outcomes and the potential risk of delayed surgical intervention, careful patient selection is essential when considering conservative management. Based on previously published reports and the clinical course of the present case, the Coca-Cola dissolution therapy may be considered under carefully controlled conditions. Suggested clinical criteria include: (1) hemodynamic stability without signs of systemic inflammatory response or sepsis; (2) absence of peritoneal irritation; (3) no radiologic evidence of bowel ischemia, perforation, or closed-loop obstruction on contrast-enhanced CT; and (4) laboratory findings not suggestive of strangulation, including the absence of marked lactate elevation.

During conservative management, continuous clinical and radiologic reassessment is mandatory. Any evidence of clinical deterioration, worsening abdominal pain, progressive inflammatory markers, or radiologic progression of obstruction should prompt timely surgical intervention. These criteria are not intended to replace established surgical principles but to provide a structured framework for cautious application of dissolution therapy in carefully selected patients.

Conclusion

We report a rare case in which a bezoar incarcerated in the second portion of the duodenum was successfully managed with a repeated Coca-Cola dissolution therapy, resulting in distal migration to the jejunum and avoidance of pancreaticoduodenectomy. This case underscores the potential role of dissolution therapy not only as a definitive treatment but also as a bridge strategy to reduce surgical invasiveness in carefully selected patients. With appropriate patient selection and vigilant monitoring, conservative management may broaden surgical options and contribute to less invasive therapeutic strategies for incarcerated gastrointestinal bezoars.

Ethical approval

The anonymized presentation of this case report did not require separate approval from the institutional ethics committee. This study was conducted according to the principles of the Declaration of Helsinki.

Consent

A written informed consent was obtained from the patient for the publication of this case report and the accompanying images. A copy of the written consent form is available for review from the Editor-in-Chief of this journal upon request.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

Y.I. conceived the case presentation and drafted the manuscript. S.M. and Y.M. took care of the management of the patient. A.S. read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no competing interests.

Research registration unique identifying number (UIN)

This case report does not require registration as a research study.

Guarantor

Yugo Ishii.

Provenance and peer review

Not commissioned, externally peer reviewed.

Data availability statement

Not applicable.