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Phytobezoar: Not an Uncommon Cause of Intestinal Obstruction

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Phytobezoar: Not an Uncommon Cause of Intestinal Obstruction ISRA MEDICAL JOURNAL Volume 3 Issue 3 Dec 2011 CASE REPORT PHYTOBEZOAR: NOT AN UNCOMMON CAUSE OF INTESTINAL OBSTRUCTION Ishtiaq Ahmed, Samia Shaheen, Sundas Ishtiaq ABSTRACT We are presenting a case report of an 18 year old boy brought in emergency with acute intestinal obstruction. An exploratory Laparotomy revealed Guava pulp and seeds making a large phytobezoars as a cause of the acute small intestinal obstruction at mid ileum. Enterotomy was done to remove the bezoars and patient had smooth recovery. KEY WORDS: Phytobezoar, Intestinal obstruction, Diagnosis, Management INTRODUCTION have been reported5, 7 . Due to change in dietary habits and improvement in medical facilities, bezoars are Bezoars were sought because they were believed to now diagnosed more commonly as a cause on have the power of a universal antidote against any intestinal obstruction in our set up. poison. It was believed that a drinking glass which contained a bezoar would neutralize any poison CASE REPORT poured into it. The word "bezoar" comes from the Persian pâdzahr (ÑÜÜå ÒÏÇ ), which literally means An 18 year old boy was admitted with five days history "antidote"1 . It has been the subject of fascination in of abdominal distension, generalized abdominal pain medical history because of the belief that it and vomiting. Past medical history was inconclusive. possesses magical power. In 1575, the surgeon Clinical examination revealed marked central Ambroise Paré believed that the bezoar didn't have abdominal distension, tenderness with localized antidote properties. It happened that a cook at Paré's guarding and absent bowel sounds. Plain abdominal court was caught stealing fine silver cutlery. In his radiograph shows multiple air fluid levels suggestive shame, the cook agreed to be poisoned. He then of acute intestinal obstruction mainly involving used the bezoar stone to no great avail, as he died in jejunum and proximal ileum. Ultrasound abdomen agony seven hours later2 . Paré had proved that the revealed dilated small gut, without any peristalsis and Bezoar stone could not cure all poisons as was presence of free fluid in the abdomen. Exploratory commonly believed at the time. Until eighteen Laparotomy revealed an obstruction at mid ileum. A century a large bezoar stone set in gold was included firm rounded mass about 6 cm long was palpable in in the inventory of the crown jewels at the time of the lumen of ileum causing complete obstruction. ascension of James I to the English thorn in 16621,3 . Enterotomy was done and it revealed a firm mass Different types of phytobezoars have been reported consisting of pulp and seeds of guava with some in literature. Most common type is “Diospyrobezoar” other resins which were removed. Rest of the gut, occurs due to ingestion of persimmons4,5 which has stomach and abdominal viscera's was normal. been identified as causing epidemics of intestinal Patient had smooth post-operative recovery and bezoars in 90% of food boluses due to eating too discharged from hospital within a week. much of the fruit which require surgery for removal. 4-6 Second most common type is due to ingestion of citrus fruit and “Trichophytobezoar” which is combination of above two 5. Other types of bezoars like Pharmacobezoars from medicine, shellac bezoar in furniture workers, lactobezoars in neonates, trichobezoars in psychiatric patients or in girls also Correspondence to: Dr. Ishtiaq Ahmed Professor of Surgery Al-Nafees Medical College Isra University, Islamabad Campus, Pakistan Fig I: Phytobezoar being removed E-mail: [email protected] through enterotomy 110 DISCUSSION perforation, steatorrhoea, intussusception, appendicitis and constipation4,7 . In contrary to A bezoar is found in Gastrointestinal tract and trichobezoar, no psychiatric association with the respiratory tract of humans as well as in animals. In phytobezoar is found in the patients14 . Most of the gastrointestinal tract it is found anywhere in patients with phytobezoars are men between the esophagus, stomach, intestines and respiratory tract. ages of 40 and 50 years. Phytobezoars are not In the esophagus it is common in young children and uncommon in childhood it has also been reported in in horses. In large intestine it is known as a fecoalith very young age in two children of twenty seven month and in trachea is called a tracheobezoar 7 . Bezoars age and six year age by Ameh and his colleagues12 . are of four types and among them Phytobezoars are Phytobezoars are usually single but multiple the most common, which are composed of vegetable phytobezoars are reported in stomach in 17% and matter such as celery, pumpkin, grape skin, prune intestine in 4% of patients 5, 15. and persimmons and it contains large amount of Abdominal radiograph, ultrasound or Computer nondigestable fibers such as cellulose, tomography scan may be helpful in the diagnosis. hemicelluloses, lignin and fruit tannins. Plain radiograph typically shows a classic obstructive Trichobezoars are gastric concretion of hair fibers pattern. Occasionally we may be able to see the which usually presents in patients with history of outline of bezoar, which is difficult to differentiate from psychiatric predisposition and in children with mental abscess or feces within the colon. Ultrasound has retardation. Pharmacobezoars consist of medication been used to detect bezoar. In a retrospective study bezoars, which in bulk will adhere, such as done by Ripolles et al.16 , ultrasound was able to cholestyramine, kayexalate resin, cavafate and detect phytobezoar in 88% of patients with small antacids. Lactobezoars are milk curd secondary to bowel obstruction. Bezoar appears as a hyperechoic infant formula, described in low birth weight neonates arc like surface with acoustic shadowing on fed on highly concentrated formula within the first ultrasound, however this feature may make it difficult week of life8 . Primary small bowel bezoars almost to differentiate it from gallstone which also has similar always present as intestinal obstruction. They usually ultrasound characteristics 11, 16. become impacted in the narrowest portion of the CT scan is rapidly becoming the first line examination small bowel, the commonest site being the terminal for the evaluation of small bowel obstruction because ileum followed by the jejunum9 , as was found in our it can exclude other causes of acute abdomen, patient. Diet and pre-existing gastroduodenal differentiate between simple obstruction and pathology contribute to the formation of bezoar. More strangulation, detect signs of concomitant intestinal than half of cases of phytobezoars had history of ischemia and can accurately define the cause, previous gastric surgery and rarely reported in degree and level of obstruction. The presence of patients with autoimmune gastritis as reported in round, non-homogenous mottled mass on CT is literature 4, 9-11. suspicion of bezoar as the cause of intestinal Phytobezoars keep on growing by the continuing obstruction found in 11% of the cases. Phytobezoar ingestion of food rich in cellulose and other can appear as a soft tissue mass without gas making indigestible materials, matted together by protein, diagnosis difficult as it can resemble an intraluminal mucus and pectin. Affected patients may remain tumour or intussusception. They also described the asymptomatic for many years and develop presence of target sign or fecal ball sign ovoid or symptoms insidiously. They are usually discovered round intraluminal mass with mottled gas pattern as an incidental finding in the patient with non- outlined by fluid or oral contrast material in the dilated specific symptoms except for an occasional small bowel at the site of obstruction, and abruptly abdominal mass or halitliosis9 . Predisposing factors collapsed lumen beyond the lesion8, 17 . The presence include the ingestion of high-fiber diet, inadequate of this sign on CT indicates that the phytobezoar mastication, previous gastric surgery producing hypo obstructing the bowel may have difficulty passing or anacidity and loss of antral pump mechanism, post through the small bowel lumen. An encapsulating surgical adhesions, ano-rectal malformations and wall caused by a gel like membrane covering the Meckel's diverticulum8,12,13 . Gastric bezoars may bezoar may also be seen on CT18 . present as epigastric pain, loss of appetite, weight Gold standard of diagnosis of gastric phytobezoars is loss, episode of distension and vomiting. Intestinal upper gastrointestinal endoscopy as it provides direct bezoars present with intermittent abdominal pain and visualization of the phytobezoars and lowers to intestinal obstruction 13. sample it for analysis. According to Andrus et al, Phytobezoars have rarely been associated with other endoscopy can definitively diagnose phytobezoar gastrointestinal complications such as peritonitis, where it appears as a dark brown, green, black mass 111 ISRA MEDICAL JOURNAL Volume 3 Issue 3 Dec 2011 of amorphous material in gastric fundus, antrum or index of suspicion. remnant stomach. They found that barium swallow identified only 25% of bezoars found endoscopically. REFERENCES Treatment therapy for bezoars is tailored to the composition of the concretion and to the underlying 1. Bala M, Appelbaum L, Almogy G "Unexpected physiological process. Available treatment methods cause of large bowel obstruction: colonic for phytobezoars include chemical dissolution, bezoar". Isr Med Assoc J 2008; 10 (11): endoscopy and surgery. Gastric phytobezoars can 829–30. be treated conservatively
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