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An Unusual Cause of Small Bowel Obstruction
CLINICAL CHALLENGES AND IMAGES IN GI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
An Unusual Cause of Small Bowel Obstruction Q2
Pedro L. Gonzalez-Cordero, Daniel Vara-Brenes, and Javier Molina-Infante Department of Gastroenterology, Hospital San Pedro de Alcantara, Cáceres, Spain
Question: A 72-year-old man with a history of hypertension presents with 5 days of vomiting, persistent hiccups, and early satiety. He also complained of constipation and periumbilical pain. Abdominal examination revealed abdominal distension and mild tenderness, but no guarding or rigidity. Laboratory parameters were within normal range. Radiograph of abdomen showed distended small bowel loops (Figure A). Abdominal ultrasonography exhibited a 39-mm gallstone-like calcium density image within a small bowel loop in the right iliac region, with full acoustic shadow distally (Figure B). Abdominal contrast-enhanced computed tomography revealed marked dilatation of small bowel loops, but did not reveal the cause of the intestinal obstruction. No gallstones, gallbladder thickening, pneumobilia, or pneumoperitoneum were observed. The patient underwent emergency exploratory laparotomy. What is the most likely diagnosis? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.11.045
Gastroenterology 2015;-:1–2 DIS 5.4.0 DTD YGAST60174 proof 20 December 2015 4:25 am ce
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CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 4 (page XXX): Small Bowel Persimmon Phytobezoar The intraoperative findings included dilated small bowel loops up to the distal ileum. Through an enterotomy at this level, a hard 4 3.5 intraluminal mass was removed (Figure C). This lesion was further confirmed to be made of undigested vegetable matter and fibrous material on histopathologic examination. Postoperative period was uneventful and the patient was discharged on postoperative day 5. Bezoars are conglomerates of indigested foreign material that accumulate in the gastrointestinal tract, responsible for 0.4%-4% of cases of mechanical intestinal obstruction.1 Although the majority of bezoars are found in the stomach, bezoars sometimes move from the stomach into the small intestine, or they can be primarily formed in the small intestine. The most common type of bezoar is the phytobezoar, which consists of indigestible food residue. Celery, pumpkins, grape skins, prunes, raisins, and especially persimmons have been related to the formation of phytobezoars.2 Retrospectively interrogated, the patient admitted a daily consumption of 3 persimmons during in-season periods over the last 8 years. He did not consume any other predisposing food on a regular basis. Some of these foods contain high amounts of nondigestible food materials, such as cellulose, hemicellulose, lignin, and tannins (leucoanthocyanins and catechins), which constitute the main components of phytobezoars. Apart from a high-fiber diet, most elderly patients suffering from gastrointestinal bezoars usually have a prior predisposing factor, such as prior gastric/ small bowel disease, abdominal surgery, diverticular disease, prior radiotherapy, and gastrointestinal dysmotility. However, 1% of patients, as the one shown here, may present without any of these predisposing factors.2 The most valuable diagnostic method is abdominal computed tomography, in which phytobezoars are visualized as an ovoid or round occupational mass in the gastrointestinal tract with air bubbles retained inside and a mottled appearance.1 Surgical removal is inevitable for cases presenting with intestinal obstruction.
References 1. 2.
Dikicier E, Altintoprak F, Ozkan OV, et al. Intestinal obstruction due to phytobezoars: an update. World J Clin Cases 2015; 3:721–726. Iwamuro M, Okada H, Matsueda K, et al. Review of the diagnosis and management of gastrointestinal bezoars. World J Gastrointest Endosc 2015;7:336–345.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60174 proof 20 December 2015 4:25 am ce
print & web 4C=FPO
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An Unusual Cause of Small Bowel Obstruction Q2
Pedro L. Gonzalez-Cordero, Daniel Vara-Brenes, and Javier Molina-Infante Department of Gastroenterology, Hospital San Pedro de Alcantara, Cáceres, Spain
Question: A 72-year-old man with a history of hypertension presents with 5 days of vomiting, persistent hiccups, and early satiety. He also complained of constipation and periumbilical pain. Abdominal examination revealed abdominal distension and mild tenderness, but no guarding or rigidity. Laboratory parameters were within normal range. Radiograph of abdomen showed distended small bowel loops (Figure A). Abdominal ultrasonography exhibited a 39-mm gallstone-like calcium density image within a small bowel loop in the right iliac region, with full acoustic shadow distally (Figure B). Abdominal contrast-enhanced computed tomography revealed marked dilatation of small bowel loops, but did not reveal the cause of the intestinal obstruction. No gallstones, gallbladder thickening, pneumobilia, or pneumoperitoneum were observed. The patient underwent emergency exploratory laparotomy. What is the most likely diagnosis? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.11.045
Gastroenterology 2015;-:1–2 DIS 5.4.0 DTD YGAST60174 proof 20 December 2015 4:25 am ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 4 (page XXX): Small Bowel Persimmon Phytobezoar The intraoperative findings included dilated small bowel loops up to the distal ileum. Through an enterotomy at this level, a hard 4 3.5 intraluminal mass was removed (Figure C). This lesion was further confirmed to be made of undigested vegetable matter and fibrous material on histopathologic examination. Postoperative period was uneventful and the patient was discharged on postoperative day 5. Bezoars are conglomerates of indigested foreign material that accumulate in the gastrointestinal tract, responsible for 0.4%-4% of cases of mechanical intestinal obstruction.1 Although the majority of bezoars are found in the stomach, bezoars sometimes move from the stomach into the small intestine, or they can be primarily formed in the small intestine. The most common type of bezoar is the phytobezoar, which consists of indigestible food residue. Celery, pumpkins, grape skins, prunes, raisins, and especially persimmons have been related to the formation of phytobezoars.2 Retrospectively interrogated, the patient admitted a daily consumption of 3 persimmons during in-season periods over the last 8 years. He did not consume any other predisposing food on a regular basis. Some of these foods contain high amounts of nondigestible food materials, such as cellulose, hemicellulose, lignin, and tannins (leucoanthocyanins and catechins), which constitute the main components of phytobezoars. Apart from a high-fiber diet, most elderly patients suffering from gastrointestinal bezoars usually have a prior predisposing factor, such as prior gastric/ small bowel disease, abdominal surgery, diverticular disease, prior radiotherapy, and gastrointestinal dysmotility. However, 1% of patients, as the one shown here, may present without any of these predisposing factors.2 The most valuable diagnostic method is abdominal computed tomography, in which phytobezoars are visualized as an ovoid or round occupational mass in the gastrointestinal tract with air bubbles retained inside and a mottled appearance.1 Surgical removal is inevitable for cases presenting with intestinal obstruction.
References 1. 2.
Dikicier E, Altintoprak F, Ozkan OV, et al. Intestinal obstruction due to phytobezoars: an update. World J Clin Cases 2015; 3:721–726. Iwamuro M, Okada H, Matsueda K, et al. Review of the diagnosis and management of gastrointestinal bezoars. World J Gastrointest Endosc 2015;7:336–345.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60174 proof 20 December 2015 4:25 am ce
print & web 4C=FPO
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