MJ
Steven and A Jabaar.
Department
of General Surgery, Stirling Royal Infirmary, Stirling
Corresponding
author: Mairi Steven, Department of General Surgery, Stirling Royal Infirmary.
Email: mairisteven@doctors.org.uk
Abstract
A
bezoar is a tightly packed collection of partially digested or undigested
material. When this material is
vegetable matter it is known as a phytobezoar, when it is hair it is a
trichobezoar and when it is medication a pharmacobezoar.
Phytobezoars are a known cause of small bowel obstruction in patients who
have had previous gastric surgery. Two
cases of small bowel obstruction caused by phytobezoars are discussed in
patients with no risk factors. The
cause, clinical features and management of phytobezoars is reviewed in an
attempt to increase awareness of this unusual cause of small bowel obstruction.
Case report
The
first case is that of a 58-year-old man who presented with a four-day history of
colicky abdominal pain, vomiting and constipation.
His past medical history was unremarkable and he had had no previous
abdominal surgery. He was not on
any medication and denied any unusual diet.
On examination his abdomen was distended and generally tender, but not
peritonitic. Bowel sounds were
tinkling. Plain abdominal X-ray
showed multiple loops of distended small bowel with fluid levels.
Blood results showed a leucocytosis, but no other abnormality.
A nasogastric tube was placed and he was fluid resuscitated.
The
following day his condition had not improved and he was taken to theatre.
At laparotomy a mass was found in the terminal ileum with an adjacent
enlarged mesenteric lymph node. This
was thought to be a polypoidal growth in the lumen of the ileum.
The proximal small bowel was distended and oedematous.
A small bowel resection was performed, removing 10 inches of ileum.
A primary sutured anastomosis was performed. The patient’s post-operative recovery was unremarkable and
he was discharged home eight days later.
Histopathology, however, revealed oedematous mucosa and in the strictured area a 25x 25x 10mm piece of partly digested vegetable material. Deep ulceration was seen at the site of obstruction, which was in keeping with food impaction. This is shown in Figure 1. There was no evidence of chronic inflammation, fibrosis or malignancy and no hair was seen.
Figure 1: This slide shows a section of small intestine with deep ulceration surrounded by fibrin, in-keeping with food impaction
The second case is that of a 72-year-old man with a three-day history of abdominal pain, vomiting and constipation. His past medical history included hypertension and a previous appendicectomy for proven acute appendicitis. On examination, his abdomen was soft and not distended. Bowel sounds were normal. Abdominal x-ray showed multiple loops of small bowel and a CT scan of his abdomen confirmed dilated loops of small bowel as far as the right iliac fossa. At laparotomy dilated and oedematous loops of small bowel were found down to the terminal ileum where there was a compressible mass. An enterotomy was performed and a mass shown in Figure 2 was removed. The mucosa of the ileum looked slightly inflamed at the site of impaction. No mucosal biopsy was taken, but pathology of the material showed this to be a mass of vegetable skin. The patient denied any unusual diet. His post-operative recovery was unremarkable and he was allowed home.
Figure 2: Mass of vegetable skin retrieved from terminal ileum
Discussion
Phytobezoars
are concretions of vegetable matter found in the gastrointestinal tract.
They are very uncommon, however, it has been reported that they account
for 2% of all small bowel obstruction.1
The incidence of gastric phytobezoars compared to small bowel
phytobezoars is unclear. One Canadian series found over a 10 year period 16 patients
with phytobezoars, 7 small bowel and 9 gastric.2 Risk factors include
eating bulky vegetables, most commonly persimmons, insulin dependent diabetes
mellitus, H2-antagonists and hypothyroidism.2
Most patients (76.3%) have had previous gastric surgery.3
Phytobezoars as well as trichobezoars occur more commonly in children and
adolescents and 80% occur in women. This,
therefore, makes these cases more unusual as both patients were men with no
history of any gastric surgery, no past medical history of note and were not on
any medication.
Clinical
presentation depends on the size of the concretion and the site. They include epigastric pain, nausea, vomiting, halitosis,
constipation and anorexia. Diagnosis
was previously difficult prior to the widespread use of endoscopy.
CT scanning can also be useful and authors have commented on a
“mottled” intraluminal mass being indicative of a phytobezoar.4
The
management of a phytobezoar may be operative or non-operative.
Both these cases were managed operatively; however, conservative measures
can be employed. These include,
nasogastric suctioning and lavage or endoscopic removal depending on the site.
Enzymatic therapy and metaclopramide can be used to improve gastric
emptying in the case of gastric phytobezoars.
In
conclusion, phytobezoars are a very rare cause of small bowel obstruction.
There are several risk factors, the most common being previous gastric
surgery. These cases highlight that
although risk factors should prompt the surgeon to consider a phytobezoar, it
can occur in their absence.
References:
Lo
CY, Lau PW Small bowel
phytobezoars: an uncommon cause of small bowel
obstruction. Aust N Z J Surg. 1994; 64(3): 187-9.
Hayes
PG, Rotstein OD Gastrointestinal Phytobezoars: Presentation and Management.
Canadian Journal of Surgery 1986; 29: 419-420.
Escamilla
C, Robles-Campos R, Parrilla-Paricio P et al Intestinal obstruction and
bezoars. Journal of the American College of Surgeons 1994; 179: 285-288.
Ripolles T, Garcia-Aguayo J, Martinez MJ, Gil P Gastrointestinal bezoars: sonographic and CT characteristics. American Journal of Roentgenology 2001; 177 (1): 65-69.