Phytobezoars are an uncommon etiology of SBO. They can be suspected in patients with co-morbidities or psychiatric diseases but diagnosis in healthy patients can be difficult, in particular if diagnosis is based solely on a physical examination and anamnesis [
19]. In the presented case we found two phytobezoars located in different regions of our patient’s bowel. The first occluded his stomach while the second occluded his jejunum, causing a double air-fluid level with significant gastric distension. Results from blood tests, in particular the presence of leukocytosis, were completely nonspecific and did not help us in our diagnosis. According to the literature, phytobezoars can be diagnosed using abdominal radiography, which can highlight air-fluid levels associated with mechanical obstruction. However, many authors agree that it is nonspecific [
6,
20]. Some authors assert that bezoars create hyperechoic acoustic shading in ultrasonography and that this tool can recognize them in 88–93% of ileal localizations [
6,
21,
22]. Its use is controversial because it is operator dependent, patient dependent, and has low sensitivity [
23]. A barium enema or endoscopy can also be used, although their diagnostic accuracy is limited [
1]. CT with contrast enhancement, which has a sensitivity of 90% and a specificity of 57% in recognizing bezoars [
6,
22,
24,
25], is now the gold standard in the diagnosis of bezoars and SBO. It permits the differential diagnosis of other bowel masses [
19] and identifies signs such as ascites, wall bowel thickening, proximal lumen dilatation, and intestinal infarction [
1]. CT can aid in choosing a conservative or a surgical/endoscopic treatment strategy; in most cases of bezoars and SBO its leads to a targeted surgical therapy. In our case, our patient’s history and CT images initially drove us to the diagnosis of tumoral gastric occlusion – bezoars were not at this time considered. For this reason, we decided on a median laparotomy, which allowed us to determine the real cause of his SBO.
The treatment of bezoars can be conservative, especially in the case of phytobezoars. Mechanical disintegration can be tried, using mechanical lithotripsy, a Dormia basket, or an electrosurgical knife [
6]. Chemical dissolution is another option, with Coca-Cola® lavages or hydrolytic solutions [
5]. Some authors have reported good results in the application of both methods [
26]. Other operative treatments depend on the size, consistency, and location of the bezoar. Small bezoars can be removed with endoscopic treatment [
27]. With larger bezoars, which can cause occlusion or bleeding, surgery is usually necessary. In these cases, laparoscopy or laparotomy is mandatory [
5,
12]. In our case, the nonspecific etiology led us to perform a laparotomy. There are different options for SBO treatment, including manual fragmentation and pushing the bezoar through the bowel as far as the caecum [
2,
10], removal per anum, or enterotomy. Bowel resection and anastomosis is required when occlusion is complicated by transmural ischemia [
12], but this was not the case in our patient, thus we decided to perform two enterotomies.