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Intestinal obstruction secondary to a colonic lithobezoar
Journal of Pediatric Surgery (2008) 43, E9–E10
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Intestinal obstruction secondary to a colonic lithobezoar Sarath Kumar Narayanan⁎, Valparambil Sayed Akbar Sherif, Plankudy Raghavan Babu, Thalakalath Kottileveetil Nandakumar Department of Pediatric Surgery, Institute of Maternal and Child Health, Medical College, Calicut, Kerala, India Received 23 January 2008; revised 9 February 2008; accepted 11 February 2008
Key words: Lithobezoar; Colon; Child; Intestinal obstruction; Pica
Abstract A bezoar is an accumulation of indigestible exogenous matter in the stomach and intestine. A myriad of ingested substances have been found impacted in the digestive tract. Bezoars are uncommon causes of intestinal obtruction during childhood. Lithobezoar, an accumulation of ingested stones within the alimentary tract, is an extremely rare clinical entity. We report one such case in a 9-year-old boy with a history of pica and long-term constipation resulting in intestinal obstruction secondary to a colonic lithobezoar. Only two such cases have been reported previously. © 2008 Published by Elsevier Inc.
Trichobezoars (ingested hair) and phytobezoars (alimentary fiber) are the commonly reported types of bezoars in children [1-3]. Lithobezoar refers to stones within the digestive tract. These are most often seen in neglected and emotionally disturbed children. A history of pica invariably precedes the formation of a lithobezoar. Intestinal obstruction may be precipitated if the problem is not recognized early. A case of intestinal obstruction secondary to a lithobezoar is described that was successfully managed by evacuation under anesthesia.
1. Case report A 9-year-old boy was referred to our institution with features of subacute intestinal obstruction. He gave a history of long-term constipation, occasional lower abdominal pain, and painful defecation. The boy was a neglected child who ⁎ Corresponding author. ‘Kedaram’ house, Mavicherry, Post Payyanur, Kannur-670307, Kerala, India. Tel.: +91 4985 325691 (res.), +91 9947099063 (Mobile). E-mail address: [email protected] (S.K. Narayanan). 0022-3468/$ – see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2008.02.065
belonged to the low socioeconomic group and lived in a large joint family. He was one of a twin pair and had 4 other siblings. Although his milestones were normal, he was a slow learner at school, lethargic, and was also emotionally disturbed. On probing further, his caregivers revealed that he had a habit of sitting alone and consuming stones and other mud particles. They had not sought medical advice for these problems. When his constipation and abdominal pain became troublesome, he was shown to a primary care physician who prescribed laxatives and suppositories for the same without being aware of his pica behavior. These medications worsened his condition, and he was subsequently referred. His vital parameters were normal and general physical examination result unremarkable. Abdomen was distended and tender, with no peritoneal signs. There were palpable fecoliths along the outer quadrants of the abdomen. A digital rectal examination revealed a loaded rectum with a prickly mass (stones of various sizes ranging from 0.5 to 2.0 cm each) along with little stools, and the gloved finger was stained with blood. A plain abdominal radiograph clinched the diagnosis showing innumerable discrete radioopaque stones in the entire colon (Fig. 1). The diagnosis of intestinal obstruction
E10
Fig. 1 Plain radiograph of the abdomen showing stones in the entire colon.
secondary to lithobezoar was made. The blood profile including a thyroid function test was within normal range. A manual evacuation under anesthesia was done and about half a kilo of stones were retrieved. We preferred this form of management as the impaction was mainly in the rectum resulting in a very painful defecation. He made a good recovery and was subsequently managed with laxatives and rectal washouts for about a week during which he passed many more of the remaining stones. The check abdominal radiographs thereafter showed clearance of all stones from the colon. The child was psychiatrically evaluated; a mild mental retardation was diagnosed and managed. He is at present symptom-free and is under the care of a child psychiatrist in a child guidance clinic. He has since not relapsed into lithophagia or any other form of pica.
2. Discussion The word bezoar comes from the Arabic word badzehr or the Persian word padzhar meaning a counter poison or an antidote [1]. The commonly reported bezoars in children are the trichobezoars and the phytobezoars [2,3]. Trichobezoars and phytobezoars manifest commonly in young girls with psychological and emotional disturbances [4]. The other types of bezoars that may be seen in pediatric age group are lactobezoars and medicinal or food bolus bezoars [5,6]. Gastric bezoars are among the etiologies of chronic childhood abdominal pain that, when undiagnosed, may result acutely in serious complications, including gastric ulceration, bleeding and perforation, intussusception, and small bowel obstruction [7]. An unusual form of long bezoar extending from stomach to the small intestine has been described as Rapunzel syndrome [8].
S.K. Narayanan et al. Bezoars result from pica, the appetite for unpalatable or nonnutritive objects. The etiology of pica is not known; it may be a consequence of parental neglect and deprivation early in life. It is more commonly observed in impoverished, emotionally disturbed children of low socioeconomic status who frequently live in distressed home environments. Lithophagia is a rare disorder that is liable to be underreported. When the bezoar is formed of ingested stones and mud particles, it is termed lithobezoar. Lithobezoars are extremely rare in the pediatric age group. Less than 5 cases are reported in English literature [9-11]. This is only the third reported case of lithobezoar presenting as an intestinal obstruction [10,11]. Intestinal perforations and peritonitis are the other complications. There are anecdotal reports of appendicitis and stomach ulcer as a result of lithobezoars. Seeking a clear history and thoroughly evaluating the suspicious cases are the keys to the management of such cases. They may also present with subtle symptoms such as failure to thrive, constipation, nonspecific abdominal pain, and may go unrecognized. Conservative management is usually successful [9] but may require a manual evacuation as in our case. Bleeding and intestinal perforation are possible hazards while using this approach; the advantage is laparotomy and its complications may be avoided. As in all cases of bezoars, a psychiatric evaluation is essential to prevent a recurrence. Earlier diagnosis of behavioral problems and associated pica, prevention of a bezoar formation, and prompt recognition of its complications should be of primary importance.
References [1] Mohanta PK, Mukhopadhyay M, Maiti S, et al. Case reports— trichobezoar in children—an uncommon problem. J Indian Assoc Pediatr Surg 2004;9:30-2. [2] Rao PL, Mitra SK, Pathak IC. Trichobezoars in children. Int Surg 1981;66(1):63-5. [3] Gürses N, Gürses N, Ozkan K, et al. Bezoars—analysis of seven cases. Z Kinderchir 1987;42(5):291-2. [4] Phillips MR, Zaheer S, Drugas GT. Gastric trichobezoar: case report and literature review. Mayo Clin Proc 1998;73:653-6. [5] DuBose V TM, Southgate WM, Hill JG. Lactobezoars: a patient series and literature review. Clin Pediatr (Phila) 2001;40(11):603-6. [6] Rao PVH, Raveenthiran V, Dhanalakshmi M. Gastric and intestinal bezoars. Indian J Gastroenterol 2001;20(3):115-6. [7] Lynch KA, Feola PG, Guenther E. Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department. Pediatr Emerg Care 2003;19(5):343-7. [8] Henry PY, Nair PMC, Jemila J, et al. Rapunzel syndrome. Indian J Pediatr 2007;74(3):872-3. [9] Vijayambika K. Lithobezoar. Indian Pediatr 2004;41(11):1168. [10] Rathi P, Rathi V. Colonic lithobezoar. Indian J Gastroenterol 1999;18(2):89. [11] Hesse AAJ, Appeadu-Mensah W, Welbeck J, et al. Childhood intestinal obstruction from lithobezoar. Afr J Pediatr Surg 2005;1(2):109-11.
www.elsevier.com/locate/jpedsurg
Intestinal obstruction secondary to a colonic lithobezoar Sarath Kumar Narayanan⁎, Valparambil Sayed Akbar Sherif, Plankudy Raghavan Babu, Thalakalath Kottileveetil Nandakumar Department of Pediatric Surgery, Institute of Maternal and Child Health, Medical College, Calicut, Kerala, India Received 23 January 2008; revised 9 February 2008; accepted 11 February 2008
Key words: Lithobezoar; Colon; Child; Intestinal obstruction; Pica
Abstract A bezoar is an accumulation of indigestible exogenous matter in the stomach and intestine. A myriad of ingested substances have been found impacted in the digestive tract. Bezoars are uncommon causes of intestinal obtruction during childhood. Lithobezoar, an accumulation of ingested stones within the alimentary tract, is an extremely rare clinical entity. We report one such case in a 9-year-old boy with a history of pica and long-term constipation resulting in intestinal obstruction secondary to a colonic lithobezoar. Only two such cases have been reported previously. © 2008 Published by Elsevier Inc.
Trichobezoars (ingested hair) and phytobezoars (alimentary fiber) are the commonly reported types of bezoars in children [1-3]. Lithobezoar refers to stones within the digestive tract. These are most often seen in neglected and emotionally disturbed children. A history of pica invariably precedes the formation of a lithobezoar. Intestinal obstruction may be precipitated if the problem is not recognized early. A case of intestinal obstruction secondary to a lithobezoar is described that was successfully managed by evacuation under anesthesia.
1. Case report A 9-year-old boy was referred to our institution with features of subacute intestinal obstruction. He gave a history of long-term constipation, occasional lower abdominal pain, and painful defecation. The boy was a neglected child who ⁎ Corresponding author. ‘Kedaram’ house, Mavicherry, Post Payyanur, Kannur-670307, Kerala, India. Tel.: +91 4985 325691 (res.), +91 9947099063 (Mobile). E-mail address: [email protected] (S.K. Narayanan). 0022-3468/$ – see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2008.02.065
belonged to the low socioeconomic group and lived in a large joint family. He was one of a twin pair and had 4 other siblings. Although his milestones were normal, he was a slow learner at school, lethargic, and was also emotionally disturbed. On probing further, his caregivers revealed that he had a habit of sitting alone and consuming stones and other mud particles. They had not sought medical advice for these problems. When his constipation and abdominal pain became troublesome, he was shown to a primary care physician who prescribed laxatives and suppositories for the same without being aware of his pica behavior. These medications worsened his condition, and he was subsequently referred. His vital parameters were normal and general physical examination result unremarkable. Abdomen was distended and tender, with no peritoneal signs. There were palpable fecoliths along the outer quadrants of the abdomen. A digital rectal examination revealed a loaded rectum with a prickly mass (stones of various sizes ranging from 0.5 to 2.0 cm each) along with little stools, and the gloved finger was stained with blood. A plain abdominal radiograph clinched the diagnosis showing innumerable discrete radioopaque stones in the entire colon (Fig. 1). The diagnosis of intestinal obstruction
E10
Fig. 1 Plain radiograph of the abdomen showing stones in the entire colon.
secondary to lithobezoar was made. The blood profile including a thyroid function test was within normal range. A manual evacuation under anesthesia was done and about half a kilo of stones were retrieved. We preferred this form of management as the impaction was mainly in the rectum resulting in a very painful defecation. He made a good recovery and was subsequently managed with laxatives and rectal washouts for about a week during which he passed many more of the remaining stones. The check abdominal radiographs thereafter showed clearance of all stones from the colon. The child was psychiatrically evaluated; a mild mental retardation was diagnosed and managed. He is at present symptom-free and is under the care of a child psychiatrist in a child guidance clinic. He has since not relapsed into lithophagia or any other form of pica.
2. Discussion The word bezoar comes from the Arabic word badzehr or the Persian word padzhar meaning a counter poison or an antidote [1]. The commonly reported bezoars in children are the trichobezoars and the phytobezoars [2,3]. Trichobezoars and phytobezoars manifest commonly in young girls with psychological and emotional disturbances [4]. The other types of bezoars that may be seen in pediatric age group are lactobezoars and medicinal or food bolus bezoars [5,6]. Gastric bezoars are among the etiologies of chronic childhood abdominal pain that, when undiagnosed, may result acutely in serious complications, including gastric ulceration, bleeding and perforation, intussusception, and small bowel obstruction [7]. An unusual form of long bezoar extending from stomach to the small intestine has been described as Rapunzel syndrome [8].
S.K. Narayanan et al. Bezoars result from pica, the appetite for unpalatable or nonnutritive objects. The etiology of pica is not known; it may be a consequence of parental neglect and deprivation early in life. It is more commonly observed in impoverished, emotionally disturbed children of low socioeconomic status who frequently live in distressed home environments. Lithophagia is a rare disorder that is liable to be underreported. When the bezoar is formed of ingested stones and mud particles, it is termed lithobezoar. Lithobezoars are extremely rare in the pediatric age group. Less than 5 cases are reported in English literature [9-11]. This is only the third reported case of lithobezoar presenting as an intestinal obstruction [10,11]. Intestinal perforations and peritonitis are the other complications. There are anecdotal reports of appendicitis and stomach ulcer as a result of lithobezoars. Seeking a clear history and thoroughly evaluating the suspicious cases are the keys to the management of such cases. They may also present with subtle symptoms such as failure to thrive, constipation, nonspecific abdominal pain, and may go unrecognized. Conservative management is usually successful [9] but may require a manual evacuation as in our case. Bleeding and intestinal perforation are possible hazards while using this approach; the advantage is laparotomy and its complications may be avoided. As in all cases of bezoars, a psychiatric evaluation is essential to prevent a recurrence. Earlier diagnosis of behavioral problems and associated pica, prevention of a bezoar formation, and prompt recognition of its complications should be of primary importance.
References [1] Mohanta PK, Mukhopadhyay M, Maiti S, et al. Case reports— trichobezoar in children—an uncommon problem. J Indian Assoc Pediatr Surg 2004;9:30-2. [2] Rao PL, Mitra SK, Pathak IC. Trichobezoars in children. Int Surg 1981;66(1):63-5. [3] Gürses N, Gürses N, Ozkan K, et al. Bezoars—analysis of seven cases. Z Kinderchir 1987;42(5):291-2. [4] Phillips MR, Zaheer S, Drugas GT. Gastric trichobezoar: case report and literature review. Mayo Clin Proc 1998;73:653-6. [5] DuBose V TM, Southgate WM, Hill JG. Lactobezoars: a patient series and literature review. Clin Pediatr (Phila) 2001;40(11):603-6. [6] Rao PVH, Raveenthiran V, Dhanalakshmi M. Gastric and intestinal bezoars. Indian J Gastroenterol 2001;20(3):115-6. [7] Lynch KA, Feola PG, Guenther E. Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department. Pediatr Emerg Care 2003;19(5):343-7. [8] Henry PY, Nair PMC, Jemila J, et al. Rapunzel syndrome. Indian J Pediatr 2007;74(3):872-3. [9] Vijayambika K. Lithobezoar. Indian Pediatr 2004;41(11):1168. [10] Rathi P, Rathi V. Colonic lithobezoar. Indian J Gastroenterol 1999;18(2):89. [11] Hesse AAJ, Appeadu-Mensah W, Welbeck J, et al. Childhood intestinal obstruction from lithobezoar. Afr J Pediatr Surg 2005;1(2):109-11.