Image of pneumoperitoneum in patient with phytobezoar.

A 61 year-old-man was referred to the emergency room with intense and acute epigastric pain after a large meal, without experiencing symptoms of nausea or vomiting. His medical history included obsessive neurosis and a Billroth I gastric resection due to a duodenal ulcer. The patient was hemodynamically stable and had a distended abdomen that was painful to the touch, with maintained peristalsis and possible peritoneal tenderness. Bowel sounds were present. The PA chest radiograph (Fig. 1) showed a crescent-shaped air image at the left infradiaphragmatic level which suggested pneumoperitoneum. A CT examination was performed using intravenous and oral contrast. The results showed no evidence of pneumoperitoneum but it confirmed that the pseudopeumoperitoneum image was the result of a marked dilatation of the gastric remnant (Fig. 2). This dilatation was due to an obstruction of the jejunum, secondary to a well-defined “pseudomass” resembling feces, consistent with a bezoar. A MPR reconstruction was performed showing dilatation proximal to the bezoar (Fig. 3). Esophagogastroduodenoscopy (EGD) confirmed the existence of a bezoar. A Coca-Cola® lavage treatment was performed via a nasogastric tube. Four days later the ECG demonstrated the complete disappearance of the bezoar.