LAUSR

We read with interest the article by Bains et al. The authors discussed a fascinating case of an apricot phytobezoar presenting as a small bowel obstruction (SBO). We would like to add upon the authors’ history and suggest an alternate management. Bezoars can be recurrent depending on the underlying condition. Chisholm et al. reported 13 patients with phytobezoars presenting with 16 episodes of SBO – importantly, 11 had undergone truncal vagotomy and pyloroplasty for peptic ulcer. Persimmon fruit are known to result in phytobezoars, a relation attributed to a soluble tannin called ‘Shibuol’, which forms a coagulum when the astringent unripe fruit comes into contact with dilute gastric acid. Obtaining a history of persimmon fruit consumption, as well as changes in diet, dentition and chewing habits, is essential in these patients. The exact location of the bezoar is important for management. Proximal bezoars may be amenable to endoscopic fragmentation and removal. When surgical management is considered for distal bezoars, laparoscopy is highly safe and effective in the management of bezoar-induced SBO with lower postoperative complications and shorter operative time and hospital stay than laparotomy. Although a bezoar is more often an intraoperative diagnosis, we would be interested to know the authors’ rationale for proceeding directly to laparotomy prior to a diagnostic laparoscopy in the setting of a stable patient with SBO without features of peritonitis/perforation. Apricots should be softened and rehydrated with hot water prior to swallowing. Educating patients is of prime importance as these dried fruits are often taken by elderly patients because they have a high fibre content. A warning sign on the commercial packs, indicating not to ingest such fruits while dry, may prevent similar complications. We appreciate the authors’ contributions in explaining this interesting presentation and reiterate that laparoscopy should precede a laparotomy in stable patients with SBO.