Esophageal bezoar in a patient with esophageal epiphrenic diverticulum.

A 57-year-old woman presented with dysphagia and postprandial epigastric fullness for about two years. Esophagogastroduodenoscopy (EGD) showed a esophageal diverticulum at the lower portion of the esophagus, and barium swallow esophagography showed a focal outpouching space (measured about 5cm in size) at the distal third of the esophagus near the esophagogastric junction (●" Fig.1). The patient reported having nausea and vomiting after eating in the past 2 days. She underwent another EGD, which revealed a 3-cm, blackish bezoar impacted in the esophageal diverticulum (●" Fig.2). The bezoar was removed with a snare basket. On reviewing her history, it was found that she had been taking Pho Pu Zi (Cordia dichotoma Forst. f.) as an appetizer for a month. Esophageal diverticulum is a rare esophageal disease and can occur anywhere in the esophagus [1]. The epiphrenic diverticulum is an acquired pulsion diverticulum that occurs near the diaphragmatic hiatus [1]. In about 80% of patients it is associated with an underlying motility disorder, such as diffuse esophageal spasm, hypertensive lower esophageal sphincter (LES), and achalasia. The dysphagia is usually due to extrinsic compression by a large food-filled diverticulum or the underlying motility disorder. Esophageal bezoars are also usually associated with an underlying motility disorder. They mainly occur de novo [2] and are typically either phytobezoars or medication bezoars [3]. Pho Pu Zi is a traditional Taiwanese appetizer, which may be ingested in large amounts during the harvesting season, when the sticky pulp of the fruit can form a phytobezoar [4]. In the present case, the large epiphrenic diverticulum resulted in stagnation of the undigested food, which trigged the formation of a bezoar. The symptoms may worsen if an esophageal bezoar progressively increases in size. EGD is mandatory for diagnosis and treatment of esophageal bezoars [5].