approximately 24 per cent of small bowel obstructions ( sbos ) are caused by bezoars .
in addition , presentation with features of acute surgical abdomen is extremely rare , accounting for only 1% of the patients .
a bezoar is a concretion of indigestible material found in the gastrointestinal tract , which usually forms in the stomach and passes into the small bowel , where it can cause sbo .
it can be classified into one of four major types : trichobezoar , pharmacobezoar , lactobezoar and phytobezoar .
trichobezoars are composed of hair and are most commonly associated with patients who have a psychiatric disorder .
phytobezoars are composed of undigested fiber from vegetables or fruits and are the most common form of bezoar encountered as a postoperative complication after gastric bypass .
a 63-year - old syrian male presented to the emergency department with a 2-day history of generalized colicky abdominal pain associated with repeated vomiting and absolute constipation .
there was no associated history of alteration of bowel habit , rectal bleeding , fever or dysuria .
his past medical history was significant for a laparotomy in 1979 due to a peptic ulcer - related complication , but he was unaware of the details .
he was also recently diagnosed with diabetes mellitus for which he was using herbal treatment consisting of boiled olive tree leaves ( olea europaea ) . on physical examination
there was a midline laparotomy scar with a reducible incisional hernia in the epigastric area .
he had mild lower abdominal tenderness with no muscle guarding and his bowel sounds were exaggerated .
rectal examination revealed no abnormalities and there was a small amount of stool in the rectum .
routine blood investigation and abdominal x - rays were obtained . apart from leukocytosis , they were unremarkable .
a contrast - enhanced ct scan was arranged and it showed features of sbo with collapse of the terminal ileum .
there was evidence of a previous gastrojejunostomy with suspected foreign bodies in the stomach and proximal ileum .
( figs  1 and 2 ) 
 figure  1:contrast - enhanced abdominal ct scan in coronal view showing evidence of gastrojejunostomy and visible foreign body in the stomach and features of small bowel obstruction . 

figure  2:sagittal ct scan view showing foreign bodies in the stomach and the ileum with transition point in the small bowel .. contrast - enhanced abdominal ct scan in coronal view showing evidence of gastrojejunostomy and visible foreign body in the stomach and features of small bowel obstruction .
sagittal ct scan view showing foreign bodies in the stomach and the ileum with transition point in the small bowel . at laparotomy
an obstructing hard foreign body was palpable in the ileum with dilatation of the proximal small bowel loops .
3 ) both foreign bodies were removed through an enterotomy and gastrotomy , respectively , and the bowel was decompressed .
after limited adhesiolysis , the abdomen was closed en mass repairing the midline hernia defect . 
 figure  3:retrieved phytobezoars . retrieved phytobezoars .
postoperative recovery was unremarkable except for a short duration of ileus , after which the patient made a steady recovery .
he was referred to the diabetology department and dietician during admission and was discharged with outpatient clinic follow - up .
a follow - up upper gi endoscopy was done and it showed evidence of a hiatus hernia with gastrooesophageal reflux disease .
the incidence of bezoar formation after gastric surgery ranges from 5 to 12 per cent .
the main pathogenesis of bezoar formation is believed to be the result of gastric dysmotility and decreased gastric secretions , which is very common after any gastric surgery [ 3 , 4 ] .
diospyrobezoars , formed after persimmon ingestion , are a distinct type of phytobezoars characterized by their hard consistency .
coca - cola ingestion combined with endoscopic techniques has been used effectively to treat gastric phytobezoars and avoid surgery .
phytobezoar should be considered in patients with previous gastric outlet surgery who present with bowel obstruction and features of acute surgical abdomen .
the presence of a well - defined intraluminal mass with a mottled gas pattern on emergency ct scan is suggestive of an intestinal phytobezoar .
guidelines include proper chewing of food , plenty of liquids with meals and avoidance of a high - fiber diet .
 approximately 24 per cent of small bowel obstructions ( sbo ) are caused by bezoars . 
 in addition , presentation with features of acute surgical abdomen is extremely rare , accounting for only 1% of the patients . 
 a bezoar is a concretion of indigestible material found in the gastrointestinal tract , which usually forms in the stomach and passes into the small bowel , where it can cause sbo . 
 we present the case of a 63-year - old male who presented with sbo following ingestion of boiled olive leaves as herbal treatment for diabetes mellitus . 