Impact of the COVID-19 Pandemic on Esophagogastroduodenoscopy and Gastric Cancer Claims in South Korea: A Nationwide, Population-Based Study

Purpose@#There has been little information about the impact of coronavirus disease 2019 (COVID-19) pandemic on esophagogastroduodenoscopy (EGD) and gastric cancer claims. This study aimed to measure the impact of COVID-19 pandemic on EGD and gastric cancer claims in South Korea. @*Materials and Methods@#This nationwide, population-based study compared the claims data of EGD, gastric cancer, early gastric cancer (EGC), advanced gastric cancer (AGC) and gastric cancer operation in 2020 and 2021 (COVID-19 era) to those in 2019 (before COVID-19 pandemic). @*Results@#The annual claims of EGD, gastric cancer, EGC, and AGC were reduced by 6.3%, 5.0%, 4.7%, and 3.6% in 2020 and by 2.2%, 1.0%, 0.6%, and 1.9% in 2021, respectively, compared to 2019. The amount of annual claims of gastric cancer operation was reduced by 8.8% in 2020, but increased by 0.9% in 2021, compared to those in 2019. The monthly claims of EGD, gastric cancer, EGC, AGC, and gastric cancer operation were mainly reduced in the first epidemic wave of COVID-19, but decreased in the 2nd to 4th epidemic wave. Compared to 2019, the monthly claim of EGD, gastric cancer, EGC, AGC, and gastric cancer operation were reduced by 28.8%, 14.3%, 18.1%, 9.2%, and 5.8% in March 2020 and by 17.2%, 10.8%, 10.3%, 7.2%, and 35.4% in April 2020, respectively. @*Conclusion@#Negative impact of the COVID-19 pandemic on EGD, gastric cancer, EGC, AGC, and gastric cancer operation was worst during the first surge of COVID-19, but decreased in the 2nd to 4th epidemic wave of the disease in 2020 and 2021.

Chasm between Public Perceptions and Epidemiological Data on Colorectal Cancer

Background/Aims@#Only a few studies have examined perceptions of the incidence and prognosis of colorectal cancer (CRC) in the general Korean population. The aim of this study was to determine public perceptions of the lifetime incidence rate and survival of CRC. @*Methods@#All adults older than 50 years who visited the Kyung Hee University Hospital at Gangdong were invited to participate in this survey for 5 months in 2021. During the study period, eligible individuals participated in this survey through a link or quick response code on a poster posted in the hospital, which was linked to a web-based questionnaire. The questionnaire used for this survey included demographic and socioeconomic data, perceptions of CRC, and awareness of the CRC incidence and 5-year survival rate. @*Results@#Among 203 respondents, 196 answers were analyzed after the exclusion of seven incomplete answers. In our survey, half of the respondents (49.5%) answered the expected lifetime incidence rate of CRC as 0% to 4.9%. Koreans perceived CRC as a more fatal disease than epidemiological data, as 70.9% of the respondents expected the 5-year survival rate of CRC to be less than 70% for the general population. However, Koreans perceived stage IV CRC as a less fatal disease than epidemiological data, because only 20.9% of the respondents expected the 5-year survival rate of stage IV CRC to be less than 10% for general population. @*Conclusions@#Koreans recognized CRC as a more common and fatal disease than actual epidemiological data of CRC. Therefore, more efforts should be made to provide more correct information on CRC for better decision-making and communication.

The Efficacy and Safety of Endoscopic Sleeve Gastroplasty as an Alternative to Laparoscopic Sleeve Gastrectomy

Endoscopic sleeve gastroplasty (ESG) is a therapeutic endoscopic technique for reducing the size of the gastric reservoir in obese patients, using a full-thickness endoscopic suturing device. The effectiveness of ESG in weight loss is significantly greater than that of high-intensity diet and lifestyle therapy and lower than that of laparoscopic sleeve gastrectomy (LSG). The efficacy at 12 months after ESG in terms of percentage of total body weight loss and excess body weight loss was approximately 16% and 60%, respectively. The well-known predictive factors for increased weight loss by ESG are good compliance with regular monitoring and post-procedure care involving a multidisciplinary team approach. Although the underlying mechanism of weight loss induced by ESG is debatable, delayed gastric emptying and early satiation are some of the proposed mechanisms. The pooled rate of adverse events after ESG reported in several meta-analysis studies ranged from 1.5% to 2.3% and the incidence of new-onset gastroesophageal reflux disease after ESG was negligible, indicating that ESG has a superior safety profile to LSG. Moreover, ESG reduced the risk of obesity-related metabolic comorbidities, evidenced by the reduction in HbA1c level, systolic blood pressure, triglyceride level, and risk of hepatic steatosis and fibrosis; it even improved the quality of life. ESG could be considered safe and qualify as an alternative treatment to LSG.

Gastrointestinal and Nongastrointestinal Complications of Esophagogastroduodenoscopy and Colonoscopy in the Real World: A Nationwide Standard Cohort Using the Common Data Model Database

Background/Aims@#The global trend of an expanding aged population has increased concerns about complications correlated with gastrointestinal (GI) endoscopy in elderly patients; however, there have been few reports published on this issue. @*Methods@#In this retrospective, observational cohort study performed between 2012 and 2017, serious complications of esophagogastroduodenoscopy (EGD), colonoscopy, and colonoscopicpolypectomy were compared between patients according to age (≥65 years vs 18–64 years). Weused the Health Insurance Review and Assessment-National Patient Samples database, previously converted to the standardized Observational Medical Outcomes Partnership-Common Data Model. Serious complications within 30 days of the procedure included both GI complications (bleeding and perforation) and non-GI complications (cerebrovascular accident [CVA], acute myocardial infarction [AMI], congestive heart failure [CHF], and death). @*Results@#A total of 387,647 patients who underwent EGD, 241,094 who underwent colonoscopy, and 89,059 who underwent colonoscopic polypectomy were assessed as part of this investiga-tion. During the study period, endoscopic procedures in the older group steadily increased in number in all endoscopy groups (all p<0.001). Further, pooled complication rates of bleeding, CVA, AMI, CHF, and death were approximately three times higher among older patients who underwent EGD or colonoscopy. Moreover, pooled complication rates of CVA, AMI, CHF, and death were approximately 2.2 to 5.0 times higher among older patients who underwent colonoscopic polypectomy. @*Conclusions@#Elderly patients experienced approximately three times more GI and non-GI complications after EGD or colonoscopy than young patients. Physicians should pay attention to the potential risks of GI endoscopy in elderly patients.

Fatal Necrotizing Fasciitis Following Uncomplicated Colonoscopic Polypectomy: A Case Report

Necrotizing fasciitis (NF) is a life-threatening infection that can be caused by various procedures or surgery and may develop in healthy elderly patients. Here, we report a case of a 66-year-old man with diabetes mellitus who underwent colonoscopic polypectomy, without complications. However, he visited the emergency department 24 hours after the procedure complaining of abdominal pain. Abdominopelvic computed tomography revealed multiple air bubbles in the right lateral abdominal muscles. After a diagnosis of NF was made, immediate surgical debridement was performed. However, despite three sessions of extensive surgical debridement and best supportive care at the intensive care unit, the patient died because of sepsis and NF-associated multiple-organ failure. In conclusion, physicians should pay special attention to the possibility of NF if a patient with risk factors for NF develops sepsis after colonoscopic polypectomy.

Gastrointestinal and Nongastrointestinal Complications of Esophagogastroduodenoscopy and Colonoscopy in the Real World: A Nationwide Standard Cohort Using the Common Data Model Database

Background/Aims@#The global trend of an expanding aged population has increased concerns about complications correlated with gastrointestinal (GI) endoscopy in elderly patients; however, there have been few reports published on this issue. @*Methods@#In this retrospective, observational cohort study performed between 2012 and 2017, serious complications of esophagogastroduodenoscopy (EGD), colonoscopy, and colonoscopicpolypectomy were compared between patients according to age (≥65 years vs 18–64 years). Weused the Health Insurance Review and Assessment-National Patient Samples database, previously converted to the standardized Observational Medical Outcomes Partnership-Common Data Model. Serious complications within 30 days of the procedure included both GI complications (bleeding and perforation) and non-GI complications (cerebrovascular accident [CVA], acute myocardial infarction [AMI], congestive heart failure [CHF], and death). @*Results@#A total of 387,647 patients who underwent EGD, 241,094 who underwent colonoscopy, and 89,059 who underwent colonoscopic polypectomy were assessed as part of this investiga-tion. During the study period, endoscopic procedures in the older group steadily increased in number in all endoscopy groups (all p<0.001). Further, pooled complication rates of bleeding, CVA, AMI, CHF, and death were approximately three times higher among older patients who underwent EGD or colonoscopy. Moreover, pooled complication rates of CVA, AMI, CHF, and death were approximately 2.2 to 5.0 times higher among older patients who underwent colonoscopic polypectomy. @*Conclusions@#Elderly patients experienced approximately three times more GI and non-GI complications after EGD or colonoscopy than young patients. Physicians should pay attention to the potential risks of GI endoscopy in elderly patients.

Fatal Necrotizing Fasciitis Following Uncomplicated Colonoscopic Polypectomy: A Case Report

Necrotizing fasciitis (NF) is a life-threatening infection that can be caused by various procedures or surgery and may develop in healthy elderly patients. Here, we report a case of a 66-year-old man with diabetes mellitus who underwent colonoscopic polypectomy, without complications. However, he visited the emergency department 24 hours after the procedure complaining of abdominal pain. Abdominopelvic computed tomography revealed multiple air bubbles in the right lateral abdominal muscles. After a diagnosis of NF was made, immediate surgical debridement was performed. However, despite three sessions of extensive surgical debridement and best supportive care at the intensive care unit, the patient died because of sepsis and NF-associated multiple-organ failure. In conclusion, physicians should pay special attention to the possibility of NF if a patient with risk factors for NF develops sepsis after colonoscopic polypectomy.

Endoscopic Diagnosis of Nonpedunculated Dysplasia during Surveillance of Ulcerative Colitis: A Survey-Based Multinational Study

Background/Aims@#Endoscopic diagnosis of dysplasia or colitic cancer in patients with ulcerative colitis (UC) is more challenging than that of colorectal neoplasia in non-colitic patients. We aimed to evaluate the accuracy of the endo-scopic diagnosis of “nonpedunculated” dysplasia or colitic cancer in UC patients. @*Methods@#Ten endoscopists from four countries were surveyed using photographs of 61 histologi-cally confirmed dysplastic or non-dysplastic lesions retrieved from the UC registry database of Asan Medical Center. The participants provided their assessment based on the given photographs and their intention to perform biopsy. @*Results@#The overall diagnostic performance of the 10 participants is summarized as follows: sensitivity of 88.2% (95% confidence interval [CI], 84.3% to 91.5%), specificity of 34.8% (95% CI, 29.1% to 40.8%), positive predictive value of 63.0% (95% CI, 60.8% to 65.2%), negative predictive value of 70.2% (95% CI, 62.7% to 76.6%), and accuracy of 64.6% (95% CI, 60.7% to 68.4%). The interobserver agreement on the inten-tion to perform a biopsy was poor (Fleiss kappa=0.169). Of the three endoscopic characteristics of the lesions, includ-ing ulceration, distinctness of the borders, and pit patterns, only neoplastic pit patterns were significantly predictive of dysplasia (odds ratio, 3.710; 95% CI, 2.001 to 6.881). The diagnostic sensitivity and specificity of neoplastic pit patterns were 68.2% (95% CI, 63.0% to 73.2%) and 63.3% (95% CI,57.3% to 69.1%), respectively. @*Conclusions@#Diagnostic per-formance based on the endoscopist’s intention to perform a biopsy for nonpedunculated potentially dysplastic lesions in UC patients was suboptimal according to this survey-based study.

Mucoepidermoid Carcinoma of the Esophagus / 대한소화기학회지

Mucoepidermoid carcinoma is a malignant tumor that occurs mainly in the salivary glands of adults and children, but rarely in the esophagus. A surgical resection is the primary treatment for mucoepidermal carcinoma, and the prognosis has been reported to be poor. A 61-year-old man was diagnosed with an esophageal nodule in upper gastrointestinal endoscopy for the purpose of a medical examination without any special symptoms and an endoscopic resection was performed for an accurate diagnosis. An endoscopic mucosal resection was performed using a band ligation for a complete resection and continuous follow-up with no evidence of recurrence or metastasis. The unknown prognosis of endoscopic resection makes it necessary to follow the patient carefully.

The current capacity and quality of colonoscopy in Korea

BACKGROUND/AIMS: Little is known for the capacity and quality of colonoscopy, and adherence to colonoscopy surveillance guidelines in Korea. This study aimed to investigate the present and potential colonoscopic capacity, colonoscopic quality, and adherence to colonoscopy surveillance guidelines in Korea. METHODS: We surveyed representative endoscopists of 72 endoscopy units from June to August 2015, using a 36-item questionnaire regarding colonoscopic capacity, quality, and adherence to colonoscopy surveillance guidelines of each hospitals. RESULTS: Among the 62 respondents who answered the questionnaire, 51 respondents were analyzed after exclusion of 11 incomplete answers. Only 1 of 3 of endoscopy units can afford to perform additional colonoscopies in addition to current practice, and the potential maximum number of colonoscopies per week was only 42. The quality of colonoscopy was variable as reporting of quality indicators of colonoscopy were considerably variable (29.4%–94.1%) between endoscopy units. Furthermore, there are substantial gaps in the adherence to colonoscopy surveillance guidelines, as concordance rate for guideline recommendation was less than 50% in most scenarios. CONCLUSIONS: The potential capacity and quality of colonoscopy in Korea was suboptimal. Considering suboptimal reporting of colonoscopic quality indicators and low adherence rate for colonoscopy surveillance guidelines, quality improvement of colonoscopy should be underlined in Korea.

Updates on the Facilities, Procedures, and Performance of the Accredited Endoscopy Unit

Endoscopic quality indicators can be classified into three categories, namely facilities and equipment, endoscopic procedures, and outcome measures. In 2019, the Korean Society of Gastrointestinal Endoscopy updated the accreditation of qualified endoscopy unit assessment items for these quality indicators to establish competence and define areas of continuous quality improvement. Here, we presented the updated program guidelines on the facilities, procedures, and performance of the accredited endoscopy unit. Many of these items have not yet been validated. However, the updated program will help in establishing competence and defining areas of continuous quality improvement in Korean endoscopic practice.

Nutritional approach as therapeutic manipulation in inflammatory bowel disease

Malnutrition is observed more frequently in patients with inflammatory bowel disease (IBD) than in the general population and associated with adverse clinical outcomes. This study aimed to review the current knowledge regarding the efficacy of dietary and nutritional intervention in IBD patients. Exclusive enteral nutrition might be inferior to corticosteroid treatment in adults with active Crohn’s disease (CD) but might even be superior considering the adverse effects of corticosteroid treatment in children. Total parenteral nutrition has no advantage over enteral nutrition, which is considered a more physiologic modality in organ function. Current guidelines do not yet recommend ω3-polyunsaturated fatty acid supplementation for the prevention and maintenance of remission in IBD patients. Dietary fiber supplementation could be effective in the relief of symptoms and maintenance of remission in ulcerative colitis (UC). Although vitamin D may be favorable to clinical course of IBD and bone density. Probiotic supplementation has proven to be effective in preventing and treating pouchitis for UC but is less effective in treating CD. Nutritional interventions not only correct nutritional deficiencies but also improve symptoms and clinical courses of the disease. Hence, nutritional approaches need to be developed to significantly evaluate the effectiveness of dietary interventions used to treat IBD.

Mucoepidermoid Carcinoma of the Esophagus / 대한소화기학회지

Mucoepidermoid carcinoma is a malignant tumor that occurs mainly in the salivary glands of adults and children, but rarely in the esophagus. A surgical resection is the primary treatment for mucoepidermal carcinoma, and the prognosis has been reported to be poor. A 61-year-old man was diagnosed with an esophageal nodule in upper gastrointestinal endoscopy for the purpose of a medical examination without any special symptoms and an endoscopic resection was performed for an accurate diagnosis. An endoscopic mucosal resection was performed using a band ligation for a complete resection and continuous follow-up with no evidence of recurrence or metastasis. The unknown prognosis of endoscopic resection makes it necessary to follow the patient carefully.

Quality Indicators and Outcome Measures of Endoscopy in the National Cancer Screening Program

PURPOSE: Quality indicators of the National Endoscopy Quality Improvement Program (NEQIP) and outcome measures of endoscopy in the National Cancer Screening Program (NCSP) in Korea are not clear. We evaluated the quality indicators of the revised NEQIP and outcome measures of endoscopy at different types of healthcare facilities participating in the NCSP. MATERIALS AND METHODS: This study was conducted between March and August 2018 in primary, secondary, and tertiary healthcare facilities that perform endoscopy as a part of the NCSP. Representative endoscopists completed a questionnaire for quality indicators of the NEQIP and provided data on outcome measures for endoscopy. RESULTS: Quality indicators of the NEQIP were mostly acceptable. However, the quality indicators for annual volume of esophagogastroduodenoscopy (EGD) and colonoscopy, training for endoscopy quality improvement by endoscopy nursing staff, colonoscopy reports, documentation of pathologic lesions, quality of endoscopy reprocessing areas, and completion of endoscopy reprocessing education programs were suboptimal. For outcome measures of EGD, the number of photo-documentations and total procedure time were higher at tertiary healthcare facilities than at other facilities (p<0.001 and p=0.023, respectively). For the outcome measures of colonoscopy, colonoscopy completion rate and waiting times for colonoscopy were significantly higher at tertiary healthcare facilities than at other facilities (both p<0.001). CONCLUSION: Outcome measures of endoscopy should be included as quality indicators of NCSP. However, universal outcome measures for all types of healthcare facilities should be established because performance levels of some outcome measures differ among individual healthcare facility types.

Quality Metrics of a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program in Korea

BACKGROUND/AIMS: Knowledge regarding the quality metrics of fecal immunochemical test (FIT)-based colorectal cancer screening programs is limited. The aim of this study was to investigate the performance and quality metrics of a FIT-based screening program. METHODS: In our screening program, asymptomatic subjects aged ≥50 years underwent an annual FIT, and subjects with positive FIT results underwent a subsequent colonoscopy. The performance of the FIT and colonoscopy was analyzed in individuals with a positive FIT who completed the program between 2009 and 2015 at a university hospital. RESULTS: Among the 51,439 screened participants, 75.1% completed the FIT. The positive rate was 1.1%, and the colonoscopy completion rate in these patients was 68.6%. The positive predictive values of cancer and advanced neoplasia were 5.5% and 19.1%, respectively. The adenoma detection rate in the patients who underwent colonoscopy after a positive FIT was 48.2% (60.0% for men and 33.6% for women). The group with the highest tertile quantitative FIT level showed a significantly higher detection rate of advanced neoplasia than the group with the lowest tertile (odds ratio, 2.6; 95% confidence interval, 1.4 to 5.1; p < 0.001). CONCLUSIONS: The quality metrics used in the United States and Europe may be directly introduced to other countries, including Korea. However, the optimal quality metrics should be established in each country.

Quality is the Key for Emerging Issues of Population-based Colonoscopy Screening / 대한소화기학회지

Colonoscopy is currently regarded as the gold standard and preferred method of screening for colorectal cancer (CRC). However, the benefit of colonoscopy screening may be blunted by low participation rate in population-based screening program. Harmful effects of population-based colonoscopy screening may include complications induced by colonoscopy itself and by sedation, psychosocial distress, potential over-diagnosis and socioeconomic burden. In addition, harmful effect of colonoscopy may increase with age and comorbidity. As the adverse event risk in population-based colonoscopy screening may offset benefit of the screening colonoscopy, the adverse events associated with screening colonoscopy should be well managed and monitored. To adopt population-based colonoscopy screening, consensus for the risk and benefits of screening colonoscopy should be formed for its potential harms, patient preference, socioeconomic considerations, quality improvement of colonoscopy as well as its efficacy for CRC prevention. As the suboptimal colonoscopy quality is a major pitfall of population-based colonoscopy screening, adequate training and provider regulation for screening colonoscopists should be the first step to minimize the variation of quality between colonoscopists. Gastroenterologists should lead quality improvement, auditing, and training associated with colonoscopy in a population-based colonoscopy screening program.

Effects of Perianal Involvement on Clinical Outcomes in Crohn's Disease over 10 Years

BACKGROUND/AIMS: There was the assumption that Crohn's disease (CD) patients with perianal lesions might have different clinical courses compared to those without. However, quantifiable data comparing the long-term outcomes between the two groups are scarce. METHODS: We retrospectively reviewed 221 consecutive patients newly diagnosed with CD and registered at the IBD clinic of Severance Hospital, in Seoul, Korea, between January 1990 and October 2005. We compared patients with perianal CD (PCD) and non-perianal CD (NPCD) in terms of clinical outcomes over 10 years. RESULTS: PCD progressed more frequently from inflammatory to complicated behavior than NPCD. Moreover, corticosteroids were prescribed in 102 patients with PCD and only 57 with NPCD (82.9% vs 58.2%, p < 0.001), immunosuppressants in 89 and 42 (72.4% vs 42.9%, p < 0.001), and anti-tumor necrosis factor α (TNF-α) in 37 and 12 (30.1% vs 12.2%, p=0.002). Cumulative hospitalization rates were 82.1% in PCD and 72.4% in NPCD (p=0.086), and surgical intervention rates were 39.8% and 51.0%, respectively (p=0.097). CONCLUSIONS: Patients with PCD were more likely than those with NPCD to be administered corticosteroids, immunosuppressants, and anti-TNF-α. However, there is no significant difference in the cumulative rates of surgical interventions or hospitalizations.

Determining the optimal surveillance interval after a colonoscopic polypectomy for the Korean population?

BACKGROUND/AIMS: Western surveillance strategies cannot be directly adapted to the Korean population. The aim of this study was to estimate the risk of metachronous neoplasia and the optimal surveillance interval in the Korean population. METHODS: Clinical and pathological data from index colonoscopy performed between June 2006 and July 2008 and who had surveillance colonoscopies up to May 2015 were compared between low- and high-risk adenoma (LRA and HRA) groups. The 3- and 5-year cumulative risk of metachronous colorectal neoplasia in both groups were compared. RESULTS: Among 895 eligible patients, surveillance colonoscopy was performed in 399 (44.6%). Most (83.3%) patients with LRA had a surveillance colonoscopy within 5 years and 70.2% of patients with HRA had a surveillance colonoscopy within 3 years. The cumulative risk of metachronous advanced adenoma was 3.2% within 5 years in the LRA group and only 1.7% within 3 years in the HRA group. The risk of metachronous neoplasia was similar between the surveillance interval of <5 and ≥5 years in the LRA group; however, it was slightly higher at surveillance interval of ≥3 than <3 years in the HRA group (9.4% vs. 2.4%). In multivariate analysis, age and the ≥3-year surveillance interval were significant independent risk factors for metachronous advanced adenoma (P=0.024 and P=0.030, respectively). CONCLUSIONS: Patients had a surveillance colonoscopy before the recommended guidelines despite a low risk of metachronous neoplasia. However, the risk of metachronous advanced adenoma was increased in elderly patients and those with a ≥3-year surveillance interval.

Disability due to Inflammatory Bowel Disease Is Correlated with Drug Compliance, Disease Activity, and Quality of Life

BACKGROUND/AIMS: The inflammatory bowel disease disability index (IBD-DI) was recently developed for IBD to assess the functional consequences and disease burden. We applied the IBD-DI to a Korean population and identified predictive factors influencing IBD-related disability. METHODS: Between March and August 2015, 322 consecutive patients with IBD were prospectively recruited. Patients completed the IBD-DI questionnaire and Crohn's and Ulcerative Colitis Questionnaire (CUCQ-8) for assessing quality of life. We examined the relationships between IBD-DI and disease activity or quality of life and analyzed predictive factors in Korean IBD patients. RESULTS: Enrolled patients completed both questionnaires. Total IBD-DI was correlated with CUCQ-8 scores in both ulcerative colitis (r=0.636, p<0.001) and Crohn’s disease (r=0.711, p<0.001). Total IBD-DI was also correlated with disease activity in both ulcerative colitis (r= −0.224, p=0.003) and Crohn’s disease (r= −0.307, p<0.001). Better drug compliance was associated with lower disability (p=0.001) and higher quality of life (p=0.003). CONCLUSIONS: Disability from IBD was correlated with disease activity and poor quality of life. Better drug compliance was associated with lower disability and higher quality of life. Our findings indicate that physicians should emphasize the importance of medication compliance for IBD patients.

Small Bowel Obstruction Caused by Aloe vera Bezoars: A Case Report / 대한소화기학회지

Small bowel obstruction is a clinical condition commonly caused by postoperative adhesion, volvulus, intussusceptions, and hernia. Small bowel obstruction due to bezoars is clinically uncommon, accounting for approximately 2-4% of all obstructions. Computed tomography (CT) is a useful method in diagnosing the cause of small bowel obstruction. However, small bowel obstruction caused by bezoars may not be detected by an abdominal CT examination. Herein, we report a rare case of small bowel obstruction by Aloe vera bezoars, which were undetected by an abdominal CT. Phytobezoars should be included in the differential diagnosis of small bowel obstruction in patients with predisposing factors, such as excessive consumption of high-fiber food and diabetes.