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Acute Surgical Abdomen Due to Phytobezoar-induced Ileal Obstruction
The Journal of Emergency Medicine, Vol. 44, No. 1, pp. e21–e23, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2011.06.059
Clinical Communications: Adults ACUTE SURGICAL ABDOMEN DUE TO PHYTOBEZOAR-INDUCED ILEAL OBSTRUCTION Nikolaos S. Salemis, MD, PHD,* Nikolaos Panagiotopoulos, MD,* Nikolaos Sdoukos, MD,† and Evangelos Niakas, MD† *Second Department of Surgery, Army General Hospital, Athens, Greece and †Department of Surgery, Athens Central Clinic, Athens, Greece Reprint Address: Nikolaos S. Salemis, MD, PHD, Second Department of Surgery, Army General Hospital, 19 Taxiarhon Street, Kapandriti, Athens 19014, Greece
, Abstract—Background: Phytobezoar-induced small bowel obstruction is an uncommon clinical entity accounting for 2–4.8% of all mechanical intestinal obstructions. In addition, presentation with features of acute surgical abdomen is extremely rare, accounting for only 1% of the patients. Objectives: The aim of this report is to present a very rare case of a phytobezoar-induced small bowel obstruction in a male patient who presented with acute surgical abdomen. A correct preoperative diagnosis was made based on the patient’s history and characteristic imaging features on the emergency computed tomography (CT) scan. Case Report: A 55-year-old man with previous gastrectomy presented with typical manifestations of acute abdomen. CT scan demonstrated dilatated small bowel loops and an intraluminal ileal mass with a mottled appearance. At exploratory laparotomy, a phytobezoar was found impacted in the terminal ileum and was removed through an enterotomy. Conclusions: 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. Ó 2013 Elsevier Inc.
all mechanical intestinal obstructions (1–5). An accurate preoperative diagnosis is often difficult and challenging due to the lack of specific symptoms. Clinical presentation of a phytobezoar-induced SBO with an acute surgical abdomen is very rare, occurring in 1.1% of the cases (6). We describe here a rare case of a phytobezoar-induced SBO in a patient with previous gastric surgery who presented with acute surgical abdomen. A correct preoperative diagnosis was made based on the patient’s history and characteristic imaging features on the emergency computed tomography (CT) scan. CASE REPORT A 55-year-old man was admitted to the Emergency Department with a 12-h history of progressively worsening abdominal pain associated with nausea and vomiting. Although the pain was initially located in the right lower abdomen, it progressively became generalized. His past medical history was unremarkable but he had undergone distal partial gastrectomy for duodenal ulcer 5 years prior. On clinical examination, the patient was distressed. His abdomen was distended with diffuse tenderness, guarding, and rebound tenderness. Bowel sounds were absent. He had a blood pressure of 160/70 mm Hg, a pulse rate of 92 beats/min, a respiratory rate of 18 breaths/min, and body temperature of 38 C. Laboratory evaluation revealed a white blood cell count of 14,420 109/L with 90.6% neutrophils, a hematocrit of 48.7%,
, Keywords—phytobezoar; intestinal obstruction; acute abdomen; computed tomography
INTRODUCTION Phytobezoar-induced small bowel obstruction (SBO) is an uncommon clinical entity accounting for 2–4.8% of
RECEIVED: 14 January 2011; FINAL SUBMISSION RECEIVED: 1 May 2011; ACCEPTED: 5 June 2011 e21
e22
N. S. Salemis et al.
Figure 1. Contrast-enhanced computed tomography scan of the abdomen demonstrating dilatated intestinal loops and a well-defined ovoid intraluminal mass with a mottled gas pattern consistent with phytobezoar (arrow).
a hemoglobin level of 163 g/L, and a platelet count of 265 109/L. Liver and kidney function tests were normal, and tumor markers were negative. Plain abdominal radiograph showed dilatated loops of small bowel with air-fluid levels suggesting intestinal obstruction. Abdominal ultrasonography was inconclusive. An emergency contrast-enhanced CT scan of the abdomen was obtained, which revealed dilatated small bowel loops and a welldefined ovoid intraluminal ileal mass with mottled appearance located near the ileocecal valve (Figure 1). Distal to the mass, a collapsed small bowel loop was noted (Figure 2). Based on the CT findings and the patient’s history of partial gastrectomy, a preliminary diagnosis of intestinal obstruction secondary to phytobezoar was made, and an emergency laparotomy was performed. At laparotomy, a phytobezoar was found impacted 20 cm from the ileocecal valve, causing complete intestinal obstruction. The mass was removed through a proximal enterotomy as it was not feasible to be fragmented and milked into the cecum (Figure 3). A thorough exploration of the small bowel and the stomach for a concomitant phytobezoar was unremarkable. The patient had an uncomplicated postoperative recovery. He was well and asymptomatic 11 months after surgery.
Figure 2. Contrast-enhanced computed tomography scan of the abdomen demonstrating a collapsed ileal loop (arrow) distal to the phytobezoar.
gastroparesis, kidney failure, hypothyroidism, and the use of drugs that affect gastric motility (2). Gastric surgery alters the physiology of the stomach by reducing gastric motor activity, by increasing the emptying of liquids and decreasing emptying of indigestible solid particles, and by decreasing hydrochloric acid secretion (6). In addition, partial gastrectomy and the presence of a gastroenteroanastomosis create a large opening and enhance the passage of large-diameter solid matter from stomach to the small bowel. Most commonly, patients have a history of bilateral truncal vagotomy plus pyloroplasty, and present with complete intestinal obstruction (6). In most cases, the impaction of the phytobezoar takes place in the narrowest segment of the small bowel, which is located 50–75 cm from the ileocecal valve (5). Abdominal CT scan is the preferred diagnostic modality for phytobezoar-induced SBO (2). The characteristic feature is the presence of a well-defined intraluminal mass with a mottled gas pattern, associated with dilatated small bowel proximally and collapsed bowel distally (3,7–9). CT is more accurate than ultrasonography and can also
DISCUSSION Phytobezoars are concretions of poorly digested fibers, skins, and seeds of fruits and vegetables that are found in the alimentary tract. They usually form in the stomach, but they can migrate to the small bowel, where they may cause obstruction (3,6). There is a slight male preponderance (1–3,5). Several predisposing factors that influence phytobezoar formation have been reported, such as previous gastric surgery, excessive consumption of fruits rich in fibers, poor dental health, insufficient mastication, diabetic
Figure 3. Photograph showing the phytobezoar fragments.
Acute Abdomen and Intestinal Phytobezoar
detect concomitant intestinal or gastric phytobezoars or an underlying small bowel disease (3,8). Based on CT scan findings, a phytobezoar-induced small bowel obstruction should be mainly differentiated from a small bowel feces sign and an impacted gallstone that has migrated through a cholecystoenteric fistula (7). An impacted gallstone leading to small bowel ileus may appear as a lucent intraluminal mass on CT scan (7). Apart from Rigler’s radiographic triad, consisting of small bowel obstruction, pneumobilia, and an ectopic radiopaque gallstone in the small bowel, the CT scan can detect the exact site of the impacted gallstone and the presence of the biliary-enteric fistula (10). Phytobezoars have not been implicated in the formation of cholecystoenteric fistulas and they are not associated with an increased incidence of gallstones. The small bowel feces sign was first described in 1995 by Mayo-Smith et al. as a CT sign consisting of particulate feculent material mixed with gas bubbles within a dilatated small bowel loop (11). This sign has been reported in 4–9.4% of the cases of small bowel obstruction (7,8,11). Delabrousse et al. studied in a comparative analysis the similarities and differences in CT appearance of obstructing bezoars and small bowel feces (12). They found that an isolated amorphous mass mottled with gas bubbles is suggestive of small bowel feces, whereas a well-defined mass with mottled appearance associated with an encapsulating wall is suggestive of a phytobezoar (12). The greater length of the feculent material found within the dilatated small bowel loop in the transition zone is the key for differentiating small bowel feces from bezoars in cases of small bowel obstruction (3,7,8). A longer mass, which is less compact in nature and lacks an encapsulating wall, is suggestive of small bowel feces (3,8). Emergency physicians should be aware that small bowel obstruction secondary to a phytobezoar, an impacted gallstone, or small bowel feces sign may have similar CT findings. The treatment of both obstructing phytobezoar and impacted gallstone is surgical. However, not all cases where the small bowel feces sign is found require surgical intervention, therefore making conservative management possible. Mayo-Smith et al. reported that 10 of the 22 patients with the small bowel feces sign on CT were treated conservatively (11). The treatment of a phytobezoar-induced SBO is surgical. The mass should be manually fragmented and pushed towards the cecum (3,5–8). When fragmentation is not feasible, an enterotomy can be fashioned to remove the bezoar, or a segmental bowel resection may even be required in the presence of complications (4,5). Enterotomy should be fashioned at a healthy bowel segment proximal to the impacted mass to avoid potential complications arising from the closure of the edematous bowel wall at the site of impaction. Enterotomy has been associated with a greater morbidity rate (5,6). During
e23
surgery, thorough exploration of the abdominal cavity is mandatory to exclude the presence of concomitant gastric or intestinal bezoars (3,6). About one third of patients have multiple intestinal bezoars (8). Laparoscopy has been used in a small series of patients with phytobezoar-induced SBO and has been associated with significantly shorter operative time and shorter hospital stay compared to the conventional approach (1). However, expertise is mandatory because laparoscopy is very difficult in the presence of dilatated and fragile intestinal loops (1). The best way to treat phytobezoar is prevention, by avoiding excessive consumption of foods rich in vegetable fibers and maintaining good eating habits, especially in patients with previous gastroduodenal surgery (2,6). CONCLUSIONS Acute surgical abdomen secondary to phytobezoarinduced ileal obstruction is a very rare clinical entity. Phytobezoar should be considered in patients with previous gastric outlet surgery presenting with acute abdomen and small bowel obstruction. The presence of a welldefined intraluminal mass with a mottled gas pattern on CT scan is suggestive of an intestinal phytobezoar. Thorough exploration of the abdominal cavity is essential to exclude a concomitant phytobezoar. REFERENCES 1. Yau KK, Siu WT, Law BK, Cheung HY, Ha JP, Li MK. Laparoscopic approach compared with conventional open approach for bezoarinduced small-bowel obstruction. Arch Surg 2005;140:972–5. 2. Bedioui H, Daghfous A, Ayadi M, et al. A report of 15 cases of smallbowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties. Gastroenterol Clin Biol 2008;32:596–600. 3. Ripolle´s T, Garcı´a-Aguayo J, Martı´nez MJ, Gil P. Gastrointestinal bezoars: sonographic and CT characteristics. AJR Am J Roentgenol 2001;177:65–9. 4. Ho TW, Koh DC. Small-bowel obstruction secondary to bezoar impaction: a diagnostic dilemma. World J Surg 2007;31:1072–8. 5. Lo CY, Lau PW. Small bowel phytobezoars: an uncommon cause of small bowel obstruction. Aust N Z J Surg 1994;64:187–9. 6. Escamilla C, Robles-Campos R, Parrilla-Paricio P, LujanMompean J, Liron-Ruiz R, Torralba-Martinez JA. Intestinal obstruction and bezoars. J Am Coll Surg 1994;179:285–8. 7. Zissin R, Osadchy A, Gutman V, Rathaus V, Shapiro-Feinberg M, Gayer G. CT findings in patients with small bowel obstruction due to phytobezoar. Emerg Radiol 2004;10:197–200. 8. Kim JH, Ha HK, Sohn MJ, et al. CT findings of phytobezoar associated with small bowel obstruction. Eur Radiol 2003;13:299–304. 9. Quiroga S, Alvarez-Castells A, Sebastia` MC, Pallisa E, Barluenga E. Small bowel obstruction secondary to bezoar: CT diagnosis. Abdom Imaging 1997;22:315–7. 10. Lassandro F, Romano S, Ragozzino A, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol 2005;185:1159–65. 11. Mayo-Smith WW, Wittenberg J, Bennett GL, Gervais DA, Gazelle GS, Mueller PR. The CT small bowel faeces sign: description and clinical significance. Clin Radiol 1995;50:765–7. 12. Delabrousse E, Lubrano J, Sailley N, Aubry S, Mantion GA, Kastler BA. Small-bowel bezoar versus small-bowel feces: CT evaluation. AJR Am J Roentgenol 2008;191:1465–8.
doi:10.1016/j.jemermed.2011.06.059
Clinical Communications: Adults ACUTE SURGICAL ABDOMEN DUE TO PHYTOBEZOAR-INDUCED ILEAL OBSTRUCTION Nikolaos S. Salemis, MD, PHD,* Nikolaos Panagiotopoulos, MD,* Nikolaos Sdoukos, MD,† and Evangelos Niakas, MD† *Second Department of Surgery, Army General Hospital, Athens, Greece and †Department of Surgery, Athens Central Clinic, Athens, Greece Reprint Address: Nikolaos S. Salemis, MD, PHD, Second Department of Surgery, Army General Hospital, 19 Taxiarhon Street, Kapandriti, Athens 19014, Greece
, Abstract—Background: Phytobezoar-induced small bowel obstruction is an uncommon clinical entity accounting for 2–4.8% of all mechanical intestinal obstructions. In addition, presentation with features of acute surgical abdomen is extremely rare, accounting for only 1% of the patients. Objectives: The aim of this report is to present a very rare case of a phytobezoar-induced small bowel obstruction in a male patient who presented with acute surgical abdomen. A correct preoperative diagnosis was made based on the patient’s history and characteristic imaging features on the emergency computed tomography (CT) scan. Case Report: A 55-year-old man with previous gastrectomy presented with typical manifestations of acute abdomen. CT scan demonstrated dilatated small bowel loops and an intraluminal ileal mass with a mottled appearance. At exploratory laparotomy, a phytobezoar was found impacted in the terminal ileum and was removed through an enterotomy. Conclusions: 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. Ó 2013 Elsevier Inc.
all mechanical intestinal obstructions (1–5). An accurate preoperative diagnosis is often difficult and challenging due to the lack of specific symptoms. Clinical presentation of a phytobezoar-induced SBO with an acute surgical abdomen is very rare, occurring in 1.1% of the cases (6). We describe here a rare case of a phytobezoar-induced SBO in a patient with previous gastric surgery who presented with acute surgical abdomen. A correct preoperative diagnosis was made based on the patient’s history and characteristic imaging features on the emergency computed tomography (CT) scan. CASE REPORT A 55-year-old man was admitted to the Emergency Department with a 12-h history of progressively worsening abdominal pain associated with nausea and vomiting. Although the pain was initially located in the right lower abdomen, it progressively became generalized. His past medical history was unremarkable but he had undergone distal partial gastrectomy for duodenal ulcer 5 years prior. On clinical examination, the patient was distressed. His abdomen was distended with diffuse tenderness, guarding, and rebound tenderness. Bowel sounds were absent. He had a blood pressure of 160/70 mm Hg, a pulse rate of 92 beats/min, a respiratory rate of 18 breaths/min, and body temperature of 38 C. Laboratory evaluation revealed a white blood cell count of 14,420 109/L with 90.6% neutrophils, a hematocrit of 48.7%,
, Keywords—phytobezoar; intestinal obstruction; acute abdomen; computed tomography
INTRODUCTION Phytobezoar-induced small bowel obstruction (SBO) is an uncommon clinical entity accounting for 2–4.8% of
RECEIVED: 14 January 2011; FINAL SUBMISSION RECEIVED: 1 May 2011; ACCEPTED: 5 June 2011 e21
e22
N. S. Salemis et al.
Figure 1. Contrast-enhanced computed tomography scan of the abdomen demonstrating dilatated intestinal loops and a well-defined ovoid intraluminal mass with a mottled gas pattern consistent with phytobezoar (arrow).
a hemoglobin level of 163 g/L, and a platelet count of 265 109/L. Liver and kidney function tests were normal, and tumor markers were negative. Plain abdominal radiograph showed dilatated loops of small bowel with air-fluid levels suggesting intestinal obstruction. Abdominal ultrasonography was inconclusive. An emergency contrast-enhanced CT scan of the abdomen was obtained, which revealed dilatated small bowel loops and a welldefined ovoid intraluminal ileal mass with mottled appearance located near the ileocecal valve (Figure 1). Distal to the mass, a collapsed small bowel loop was noted (Figure 2). Based on the CT findings and the patient’s history of partial gastrectomy, a preliminary diagnosis of intestinal obstruction secondary to phytobezoar was made, and an emergency laparotomy was performed. At laparotomy, a phytobezoar was found impacted 20 cm from the ileocecal valve, causing complete intestinal obstruction. The mass was removed through a proximal enterotomy as it was not feasible to be fragmented and milked into the cecum (Figure 3). A thorough exploration of the small bowel and the stomach for a concomitant phytobezoar was unremarkable. The patient had an uncomplicated postoperative recovery. He was well and asymptomatic 11 months after surgery.
Figure 2. Contrast-enhanced computed tomography scan of the abdomen demonstrating a collapsed ileal loop (arrow) distal to the phytobezoar.
gastroparesis, kidney failure, hypothyroidism, and the use of drugs that affect gastric motility (2). Gastric surgery alters the physiology of the stomach by reducing gastric motor activity, by increasing the emptying of liquids and decreasing emptying of indigestible solid particles, and by decreasing hydrochloric acid secretion (6). In addition, partial gastrectomy and the presence of a gastroenteroanastomosis create a large opening and enhance the passage of large-diameter solid matter from stomach to the small bowel. Most commonly, patients have a history of bilateral truncal vagotomy plus pyloroplasty, and present with complete intestinal obstruction (6). In most cases, the impaction of the phytobezoar takes place in the narrowest segment of the small bowel, which is located 50–75 cm from the ileocecal valve (5). Abdominal CT scan is the preferred diagnostic modality for phytobezoar-induced SBO (2). The characteristic feature is the presence of a well-defined intraluminal mass with a mottled gas pattern, associated with dilatated small bowel proximally and collapsed bowel distally (3,7–9). CT is more accurate than ultrasonography and can also
DISCUSSION Phytobezoars are concretions of poorly digested fibers, skins, and seeds of fruits and vegetables that are found in the alimentary tract. They usually form in the stomach, but they can migrate to the small bowel, where they may cause obstruction (3,6). There is a slight male preponderance (1–3,5). Several predisposing factors that influence phytobezoar formation have been reported, such as previous gastric surgery, excessive consumption of fruits rich in fibers, poor dental health, insufficient mastication, diabetic
Figure 3. Photograph showing the phytobezoar fragments.
Acute Abdomen and Intestinal Phytobezoar
detect concomitant intestinal or gastric phytobezoars or an underlying small bowel disease (3,8). Based on CT scan findings, a phytobezoar-induced small bowel obstruction should be mainly differentiated from a small bowel feces sign and an impacted gallstone that has migrated through a cholecystoenteric fistula (7). An impacted gallstone leading to small bowel ileus may appear as a lucent intraluminal mass on CT scan (7). Apart from Rigler’s radiographic triad, consisting of small bowel obstruction, pneumobilia, and an ectopic radiopaque gallstone in the small bowel, the CT scan can detect the exact site of the impacted gallstone and the presence of the biliary-enteric fistula (10). Phytobezoars have not been implicated in the formation of cholecystoenteric fistulas and they are not associated with an increased incidence of gallstones. The small bowel feces sign was first described in 1995 by Mayo-Smith et al. as a CT sign consisting of particulate feculent material mixed with gas bubbles within a dilatated small bowel loop (11). This sign has been reported in 4–9.4% of the cases of small bowel obstruction (7,8,11). Delabrousse et al. studied in a comparative analysis the similarities and differences in CT appearance of obstructing bezoars and small bowel feces (12). They found that an isolated amorphous mass mottled with gas bubbles is suggestive of small bowel feces, whereas a well-defined mass with mottled appearance associated with an encapsulating wall is suggestive of a phytobezoar (12). The greater length of the feculent material found within the dilatated small bowel loop in the transition zone is the key for differentiating small bowel feces from bezoars in cases of small bowel obstruction (3,7,8). A longer mass, which is less compact in nature and lacks an encapsulating wall, is suggestive of small bowel feces (3,8). Emergency physicians should be aware that small bowel obstruction secondary to a phytobezoar, an impacted gallstone, or small bowel feces sign may have similar CT findings. The treatment of both obstructing phytobezoar and impacted gallstone is surgical. However, not all cases where the small bowel feces sign is found require surgical intervention, therefore making conservative management possible. Mayo-Smith et al. reported that 10 of the 22 patients with the small bowel feces sign on CT were treated conservatively (11). The treatment of a phytobezoar-induced SBO is surgical. The mass should be manually fragmented and pushed towards the cecum (3,5–8). When fragmentation is not feasible, an enterotomy can be fashioned to remove the bezoar, or a segmental bowel resection may even be required in the presence of complications (4,5). Enterotomy should be fashioned at a healthy bowel segment proximal to the impacted mass to avoid potential complications arising from the closure of the edematous bowel wall at the site of impaction. Enterotomy has been associated with a greater morbidity rate (5,6). During
e23
surgery, thorough exploration of the abdominal cavity is mandatory to exclude the presence of concomitant gastric or intestinal bezoars (3,6). About one third of patients have multiple intestinal bezoars (8). Laparoscopy has been used in a small series of patients with phytobezoar-induced SBO and has been associated with significantly shorter operative time and shorter hospital stay compared to the conventional approach (1). However, expertise is mandatory because laparoscopy is very difficult in the presence of dilatated and fragile intestinal loops (1). The best way to treat phytobezoar is prevention, by avoiding excessive consumption of foods rich in vegetable fibers and maintaining good eating habits, especially in patients with previous gastroduodenal surgery (2,6). CONCLUSIONS Acute surgical abdomen secondary to phytobezoarinduced ileal obstruction is a very rare clinical entity. Phytobezoar should be considered in patients with previous gastric outlet surgery presenting with acute abdomen and small bowel obstruction. The presence of a welldefined intraluminal mass with a mottled gas pattern on CT scan is suggestive of an intestinal phytobezoar. Thorough exploration of the abdominal cavity is essential to exclude a concomitant phytobezoar. REFERENCES 1. Yau KK, Siu WT, Law BK, Cheung HY, Ha JP, Li MK. Laparoscopic approach compared with conventional open approach for bezoarinduced small-bowel obstruction. Arch Surg 2005;140:972–5. 2. Bedioui H, Daghfous A, Ayadi M, et al. A report of 15 cases of smallbowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties. Gastroenterol Clin Biol 2008;32:596–600. 3. Ripolle´s T, Garcı´a-Aguayo J, Martı´nez MJ, Gil P. Gastrointestinal bezoars: sonographic and CT characteristics. AJR Am J Roentgenol 2001;177:65–9. 4. Ho TW, Koh DC. Small-bowel obstruction secondary to bezoar impaction: a diagnostic dilemma. World J Surg 2007;31:1072–8. 5. Lo CY, Lau PW. Small bowel phytobezoars: an uncommon cause of small bowel obstruction. Aust N Z J Surg 1994;64:187–9. 6. Escamilla C, Robles-Campos R, Parrilla-Paricio P, LujanMompean J, Liron-Ruiz R, Torralba-Martinez JA. Intestinal obstruction and bezoars. J Am Coll Surg 1994;179:285–8. 7. Zissin R, Osadchy A, Gutman V, Rathaus V, Shapiro-Feinberg M, Gayer G. CT findings in patients with small bowel obstruction due to phytobezoar. Emerg Radiol 2004;10:197–200. 8. Kim JH, Ha HK, Sohn MJ, et al. CT findings of phytobezoar associated with small bowel obstruction. Eur Radiol 2003;13:299–304. 9. Quiroga S, Alvarez-Castells A, Sebastia` MC, Pallisa E, Barluenga E. Small bowel obstruction secondary to bezoar: CT diagnosis. Abdom Imaging 1997;22:315–7. 10. Lassandro F, Romano S, Ragozzino A, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol 2005;185:1159–65. 11. Mayo-Smith WW, Wittenberg J, Bennett GL, Gervais DA, Gazelle GS, Mueller PR. The CT small bowel faeces sign: description and clinical significance. Clin Radiol 1995;50:765–7. 12. Delabrousse E, Lubrano J, Sailley N, Aubry S, Mantion GA, Kastler BA. Small-bowel bezoar versus small-bowel feces: CT evaluation. AJR Am J Roentgenol 2008;191:1465–8.