A giant gastric bezoar in Billroth II stomach: a case report on successful endoscopic removal via repeated fragmentation and dissolution technique negating the need for surgical intervention

A 76-year-old gentleman presented with anemia. He had a history of perforated duodenal ulcer six years ago, with Billroth II repair performed. A large gastric bezoar (8x6 cm(2)) with a clean base ulcer at the anastomotic junction was found during the initial oesophago-gastro-duodenoscopy (OGDS). Rapid urease test was negative. He presented with melena during the subsequent follow up (OGDS showed a Forrest Ib prepylori ulcer). We have successfully removed the gastric bezoar with dissolution therapy initially (injection of coke-cola into the bezoar, followed by drinking 325 mL Coca-Cola(TM) twice daily), followed by four attempts of OGDS with endoscopic fragmentation. Histopathology reported as degenerated vegetable matter, acellular debris mixed with scattered fungal and bacterial colonies, which was compatible with bezoar. Follow-up OGDS showed complete clearance of the bezoar. Coca-ColaTM ingestion should be considered as initial treatment as it is non-invasive, and it enables further successful endoscopic fragmentation.