- Email: [email protected]
Small Bowel Obstruction Secondary to a Mushroom Bezoar: Case Report
International Journal of Gerontology 6 (2012) 295e297
Contents lists available at SciVerse ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Case Report
Small Bowel Obstruction Secondary to a Mushroom Bezoar: Case Reportq Cuiping Liu 1, Haijun Deng 2, Zhenshu Zhang 1, Lan Bai 3 * 1
Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, 2 Department of General Surgery, 3 Department of Huiqiao Building, Nanfang Hospital, Southern Medical University, Guangzhou Road 1838, Guangzhou 510515, Guangdong Province, China
a r t i c l e i n f o
s u m m a r y
Article history: Received 17 March 2011 Received in revised form 1 May 2011 Accepted 9 May 2011 Available online 21 March 2012
A bezoar is an accumulation of indigestible exogenous matter in the stomach and the intestine. The clinical diagnosis of bezoar is challenging, and initial radiographs are frequently nondiagnostic. Computed tomography (CT) has become a useful method in diagnosing the presence and cause of small bowel obstruction. The most common CT finding of phytobezoars includes a round or ovoid mass containing mottled gas at the obstructed site. We report one case of small bowel obstruction secondary to bezoar that is composed of mushroom, but without a characteristic bezoar CT imaging. Copyright Ó 2012, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: computed tomography, phytobezoars, small bowel obstruction
1. Introduction Small bowel obstruction (SBO) is a common acute presentation in any general surgical unit. However, its diagnosis and management may often be difficult because of its myriad causes1. SBO secondary to bezoar impaction is considerably less common, with a reported frequency of around 4%2, and is rarely diagnosed preoperatively. In this report, we describe a patient who had an obstructive small bowel phytobezoar; the bezoar was composed of mushroom. 2. Patient’s presentation A 76-year-old vegetarian monk was admitted at a district hospital with a history of abdominal pain, which was not associated with nausea or vomiting, for the past 3 days. There was no known history of constipation, diabetes, or gastric surgery. Erect abdominal plain film demonstrated dilated loops of small bowel with airefluid levels suggesting SBO. The abdominal computed tomography (CT) showed extensive dilated small bowel with airefluid filled loops, and local bowel wall thickening mainly in the middle abdomen with a suspicious concentric circle sign (Fig. 1). The
q All authors have no competing interests. We only want to report this first case report of our hospital to the public. * Correspondence to: Dr Lan Bai, Department of Huiqiao Building, Nanfang Hospital, Southern Medical University, Guangzhou Road 1838, Guangzhou 510515, Guangdong Province, China. E-mail address: [email protected] (L. Bai).
diagnosis of intestinal obstruction secondary to intussusception was evoked on these CT findings, and a series of conservative treatments such as nasogastric suction, decompression, intravenous fluids, and antibiotics were administered for nearly 10 days, but the patient showed no improvement. Upon admission to our hospital, the patient was conscious during examination, with stable vital signs including a heart rate of 106 beats/min, a blood pressure of 157/71 mmHg, and a body temperature of 37.3 C. Physical examination revealed abdominal distension, hypoactive bowel sounds, and abdominal tenderness but without rebound tenderness. The digital rectal examination was normal. Laboratory data on admission showed white blood cells 12.79 G/L, neutrophil 11.24 G/L, serum albumin 29.5 g/L, and arterial oxygen saturation 89.2%. Additionally, the coagulation panel, hemoglobin, and aminotransferase were within normal limits. Imaging specialist suspected a tumor in the descending colon while reviewing the CT images from the outside institution. Abdominal ultrasound revealed dilated loops of small bowel with gas-filled levels suggesting obstruction of the small intestine, and it also showed fluid collection around the intestinal wall, whose maximum diameter was 3.3 cm. Based on physical examination and abdominal ultrasound inspection, the conservative methods carried out for nearly 10 days were not effective. In fact, they gradually aggravated the patient’s clinical manifestation. Thus, an exploratory laparotomy was performed. The intraoperative findings revealed that the SBO was caused by the bolus mass located in the ileum 20 cm proximal to the valve. The patient underwent enterotomy and removal of a 4.5-cm bezoar. The bezoar was composed of an undigested mushroom (Fig. 2). The postsurgical period was uncomplicated.
1873-9598/$ e see front matter Copyright Ó 2012, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.ijge.2011.09.008
296
C. Liu et al.
Fig. 1. CT scans show extensive dilated small bowel with airefluid filled loops suggesting obstruction and an intraluminal suspected mass (arrows).
3. Discussion The word bezoar comes from the Arabic word “bazahr,” for the hardened contents of the Syrian goat’s stomach3. Bezoars result from ingestion of foreign material that accumulates in the gastrointestinal tract because of large particle size, indigestibility, gastric outlet obstruction, or intestinal stasis4. The common types of bezoars include lactobezoars, which are unique to neonates; trichobezoars, which are seen in children and young adults; and phytobezoars, typically seen in the elderly and postgastrectomy patients. Phytobezoars are the most common and are composed of poorly digested fruit and vegetable fibers such as oranges or persimmons. The main risk factors are abnormal mastication, vegetarian diet, ingestion of persimmon, previous gastric surgery, diabetic gastroparesis, and hypothyroidism5e8. Bezoars often form in the stomach, but following fragmentation, they may migrate into the small bowel and lead to mechanical
Fig. 2. Photograph taken after enterotomy shows the bezoar.
obstruction, so small bowel bezoars are often found in association with gastric bezoars9,10. They usually become impacted in the narrowest portion of the small bowel (i.e., 50e75 cm proximal to the ileocecal valve) or at the valve itself7. However, our patient’s bezoar was located in the ileum 20 cm proximal to the valve. The most common presenting features of SBO are abdominal pain, nausea, vomiting, constipation, and complications such as intestinal obstruction and perforation. Since the findings are nonspecific, the diagnosis is rarely made clinically3. Plain abdominal radiography, barium studies, and CT are all used to identify the causes of SBO. Plain abdominal radiography may show obstruction occlusive syndrome. However, it is limited in the diagnosis of SBO caused by phytobezoars. Barium studies are able to detect an intraluminal filling defect evocative of bezoars. CT has become a useful method in the diagnosis of SBO, because it can show the cause, location, and degree of obstruction11,12. An important advantage of CT over barium studies in evaluating SBO is that a diagnosis is possible even without the use of enteric contrast material because fluid- and gas-filled intestines are necessary in a barium study13,14. The most common CT finding of phytobezoars includes a round or ovoid mass containing mottled gas at the obstructed site. Dilated loops and collapsed or normal appearing bowel are seen near this obstructed transition zone. Sometimes a small bowel phytobezoar can be seen as a soft tissue mass without gas and resembles a tumor or intussusceptions6,7. Appropriate treatments for small bowel bezoars are always carried out surgically. At the time of surgery, milking the bezoars into the cecum is the procedure of choice. If this is not possible, enterotomy may become necessary. Some bezoars with soft textures can be broken during the operation, and can be milked into the large intestine, whereas bezoars with tough textures are difficult to reshape into smaller pieces. If they are burst open with force, this will likely cause intestinal injury. In this patient, the mushroom was soft but had a certain toughness, so it was difficult to manually fragment, and milk it into the cecum, which is why exploratory laparotomy was performed.
Small Bowel Obstruction Secondary to a Bezoar
Mushroom bezoar is a rare cause of small intestinal obstruction. Only two cases have been previously reported15,16. In this case, bolus intake of vegetables due to either dental problems or chewing habits may be the main factors leading to bezoar. However, lack of a history of gastric surgery or diabetic gastroparesis, and long-term vegetarian diet may be another important factor for our patient. Because the mushroom was a soft tissue mass, we theorize that it lacked a characteristic bezoar appearance (during imaging) and resembled a tumor or intussusceptions in this case. Further studies should be carried out to investigate the mechanism of bezoars. In conclusion, bezoar-induced SBO is uncommon and remains a diagnostic and management challenge. Although many imaging tests are used to identify small bowel bezoars at present, timely surgical treatment is necessary. 4. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-inChief of this journal.
Acknowledgments We thank the imaging specialisteprofessor Yikai Xu for analyzing the CT images.
297
References 1. Menzies D. Peritoneal adhesions. Incidence, cause and prevention. Surg Annu. 1992;24:27e45. 2. Ho TW, Koh DC. Small bowel obstruction secondary to bezoar impaction: a diagnostric dilemma. World J Surg. 2007;31:1072e1078. 3. Salem M, Fouda R, Fouda U, et al. Rapunzel and pregnancy. South Med J. 2009;102:106e107. 4. Agrawal V, Joshi MK, Jain BK, et al. Plastricobezoardanother new entity for Rapunzel syndrome. Indian J Pediatr. 2009;76:229e230. 5. Malhotra A, Jones L, Drugas G. Simultaneous gastric and small intestinal trichobezoars. Pediatr Emerg Care. 2008;24:774e776. 6. Koktener A, Dilmen G, Turkay C, et al. Small bowel obstruction caused by phytobezoar and associated with vitamin B12 deficiency. South Med J. 2006;99:1013e1014. 7. Yildirim T, Yildirim S, Barutcu O, et al. Small bowel obstruction due to phytobezoar: CT diagnosis. Eur Radiol. 2002;12:2659e26561. 8. Escamilla C, Robles-Campos R, Parrilla-Paricio P, et al. Intestinal obstruction and bezoars. J Am Coll Surg. 1994;179:285e288. 9. Zissin R, Osadchy A, Gutman V, et al. CT finding in patients with small bowel obstruction due to phytobezoar. Emerg Radiol. 2004;10:197e200. 10. Stemberg A, Coscas D, Fireman Z. Gastric phytobezoar. Harefuah. 1996;130: 316e319. 11. Frager D, Medwid SW, Jw Baer, et al. CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause. Am J Roentgenol. 1994;162:37e41. 12. Maglinte DD, Gage SN, Harmon BH, et al. Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology. 1993;188:61e64. 13. Quiroga S, Alvarez-Castells A, Sebastia MC, et al. Small bowel obstruction secondary to bezoar: CT diagnosis. Abdom Imaging. 1997;22:315e317. 14. Gayer G, Jonas T, Apter S, et al. Bezoars in the stomach and small bowel: CT appearance. Clin Radiol. 1999;54:228e232. 15. Tan KB, Premasiri MK, Isaac J, et al. Mushroom bezoar: a rare cause of small intestinal obstruction. Pathology. 2004;36:207e208. 16. Arnal-Etienne S, Puttemans T. Small bowel obstruction due to a mushroom bezoar. JBR-BTR. 2009;92:114.
Contents lists available at SciVerse ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Case Report
Small Bowel Obstruction Secondary to a Mushroom Bezoar: Case Reportq Cuiping Liu 1, Haijun Deng 2, Zhenshu Zhang 1, Lan Bai 3 * 1
Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, 2 Department of General Surgery, 3 Department of Huiqiao Building, Nanfang Hospital, Southern Medical University, Guangzhou Road 1838, Guangzhou 510515, Guangdong Province, China
a r t i c l e i n f o
s u m m a r y
Article history: Received 17 March 2011 Received in revised form 1 May 2011 Accepted 9 May 2011 Available online 21 March 2012
A bezoar is an accumulation of indigestible exogenous matter in the stomach and the intestine. The clinical diagnosis of bezoar is challenging, and initial radiographs are frequently nondiagnostic. Computed tomography (CT) has become a useful method in diagnosing the presence and cause of small bowel obstruction. The most common CT finding of phytobezoars includes a round or ovoid mass containing mottled gas at the obstructed site. We report one case of small bowel obstruction secondary to bezoar that is composed of mushroom, but without a characteristic bezoar CT imaging. Copyright Ó 2012, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: computed tomography, phytobezoars, small bowel obstruction
1. Introduction Small bowel obstruction (SBO) is a common acute presentation in any general surgical unit. However, its diagnosis and management may often be difficult because of its myriad causes1. SBO secondary to bezoar impaction is considerably less common, with a reported frequency of around 4%2, and is rarely diagnosed preoperatively. In this report, we describe a patient who had an obstructive small bowel phytobezoar; the bezoar was composed of mushroom. 2. Patient’s presentation A 76-year-old vegetarian monk was admitted at a district hospital with a history of abdominal pain, which was not associated with nausea or vomiting, for the past 3 days. There was no known history of constipation, diabetes, or gastric surgery. Erect abdominal plain film demonstrated dilated loops of small bowel with airefluid levels suggesting SBO. The abdominal computed tomography (CT) showed extensive dilated small bowel with airefluid filled loops, and local bowel wall thickening mainly in the middle abdomen with a suspicious concentric circle sign (Fig. 1). The
q All authors have no competing interests. We only want to report this first case report of our hospital to the public. * Correspondence to: Dr Lan Bai, Department of Huiqiao Building, Nanfang Hospital, Southern Medical University, Guangzhou Road 1838, Guangzhou 510515, Guangdong Province, China. E-mail address: [email protected] (L. Bai).
diagnosis of intestinal obstruction secondary to intussusception was evoked on these CT findings, and a series of conservative treatments such as nasogastric suction, decompression, intravenous fluids, and antibiotics were administered for nearly 10 days, but the patient showed no improvement. Upon admission to our hospital, the patient was conscious during examination, with stable vital signs including a heart rate of 106 beats/min, a blood pressure of 157/71 mmHg, and a body temperature of 37.3 C. Physical examination revealed abdominal distension, hypoactive bowel sounds, and abdominal tenderness but without rebound tenderness. The digital rectal examination was normal. Laboratory data on admission showed white blood cells 12.79 G/L, neutrophil 11.24 G/L, serum albumin 29.5 g/L, and arterial oxygen saturation 89.2%. Additionally, the coagulation panel, hemoglobin, and aminotransferase were within normal limits. Imaging specialist suspected a tumor in the descending colon while reviewing the CT images from the outside institution. Abdominal ultrasound revealed dilated loops of small bowel with gas-filled levels suggesting obstruction of the small intestine, and it also showed fluid collection around the intestinal wall, whose maximum diameter was 3.3 cm. Based on physical examination and abdominal ultrasound inspection, the conservative methods carried out for nearly 10 days were not effective. In fact, they gradually aggravated the patient’s clinical manifestation. Thus, an exploratory laparotomy was performed. The intraoperative findings revealed that the SBO was caused by the bolus mass located in the ileum 20 cm proximal to the valve. The patient underwent enterotomy and removal of a 4.5-cm bezoar. The bezoar was composed of an undigested mushroom (Fig. 2). The postsurgical period was uncomplicated.
1873-9598/$ e see front matter Copyright Ó 2012, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.ijge.2011.09.008
296
C. Liu et al.
Fig. 1. CT scans show extensive dilated small bowel with airefluid filled loops suggesting obstruction and an intraluminal suspected mass (arrows).
3. Discussion The word bezoar comes from the Arabic word “bazahr,” for the hardened contents of the Syrian goat’s stomach3. Bezoars result from ingestion of foreign material that accumulates in the gastrointestinal tract because of large particle size, indigestibility, gastric outlet obstruction, or intestinal stasis4. The common types of bezoars include lactobezoars, which are unique to neonates; trichobezoars, which are seen in children and young adults; and phytobezoars, typically seen in the elderly and postgastrectomy patients. Phytobezoars are the most common and are composed of poorly digested fruit and vegetable fibers such as oranges or persimmons. The main risk factors are abnormal mastication, vegetarian diet, ingestion of persimmon, previous gastric surgery, diabetic gastroparesis, and hypothyroidism5e8. Bezoars often form in the stomach, but following fragmentation, they may migrate into the small bowel and lead to mechanical
Fig. 2. Photograph taken after enterotomy shows the bezoar.
obstruction, so small bowel bezoars are often found in association with gastric bezoars9,10. They usually become impacted in the narrowest portion of the small bowel (i.e., 50e75 cm proximal to the ileocecal valve) or at the valve itself7. However, our patient’s bezoar was located in the ileum 20 cm proximal to the valve. The most common presenting features of SBO are abdominal pain, nausea, vomiting, constipation, and complications such as intestinal obstruction and perforation. Since the findings are nonspecific, the diagnosis is rarely made clinically3. Plain abdominal radiography, barium studies, and CT are all used to identify the causes of SBO. Plain abdominal radiography may show obstruction occlusive syndrome. However, it is limited in the diagnosis of SBO caused by phytobezoars. Barium studies are able to detect an intraluminal filling defect evocative of bezoars. CT has become a useful method in the diagnosis of SBO, because it can show the cause, location, and degree of obstruction11,12. An important advantage of CT over barium studies in evaluating SBO is that a diagnosis is possible even without the use of enteric contrast material because fluid- and gas-filled intestines are necessary in a barium study13,14. The most common CT finding of phytobezoars includes a round or ovoid mass containing mottled gas at the obstructed site. Dilated loops and collapsed or normal appearing bowel are seen near this obstructed transition zone. Sometimes a small bowel phytobezoar can be seen as a soft tissue mass without gas and resembles a tumor or intussusceptions6,7. Appropriate treatments for small bowel bezoars are always carried out surgically. At the time of surgery, milking the bezoars into the cecum is the procedure of choice. If this is not possible, enterotomy may become necessary. Some bezoars with soft textures can be broken during the operation, and can be milked into the large intestine, whereas bezoars with tough textures are difficult to reshape into smaller pieces. If they are burst open with force, this will likely cause intestinal injury. In this patient, the mushroom was soft but had a certain toughness, so it was difficult to manually fragment, and milk it into the cecum, which is why exploratory laparotomy was performed.
Small Bowel Obstruction Secondary to a Bezoar
Mushroom bezoar is a rare cause of small intestinal obstruction. Only two cases have been previously reported15,16. In this case, bolus intake of vegetables due to either dental problems or chewing habits may be the main factors leading to bezoar. However, lack of a history of gastric surgery or diabetic gastroparesis, and long-term vegetarian diet may be another important factor for our patient. Because the mushroom was a soft tissue mass, we theorize that it lacked a characteristic bezoar appearance (during imaging) and resembled a tumor or intussusceptions in this case. Further studies should be carried out to investigate the mechanism of bezoars. In conclusion, bezoar-induced SBO is uncommon and remains a diagnostic and management challenge. Although many imaging tests are used to identify small bowel bezoars at present, timely surgical treatment is necessary. 4. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-inChief of this journal.
Acknowledgments We thank the imaging specialisteprofessor Yikai Xu for analyzing the CT images.
297
References 1. Menzies D. Peritoneal adhesions. Incidence, cause and prevention. Surg Annu. 1992;24:27e45. 2. Ho TW, Koh DC. Small bowel obstruction secondary to bezoar impaction: a diagnostric dilemma. World J Surg. 2007;31:1072e1078. 3. Salem M, Fouda R, Fouda U, et al. Rapunzel and pregnancy. South Med J. 2009;102:106e107. 4. Agrawal V, Joshi MK, Jain BK, et al. Plastricobezoardanother new entity for Rapunzel syndrome. Indian J Pediatr. 2009;76:229e230. 5. Malhotra A, Jones L, Drugas G. Simultaneous gastric and small intestinal trichobezoars. Pediatr Emerg Care. 2008;24:774e776. 6. Koktener A, Dilmen G, Turkay C, et al. Small bowel obstruction caused by phytobezoar and associated with vitamin B12 deficiency. South Med J. 2006;99:1013e1014. 7. Yildirim T, Yildirim S, Barutcu O, et al. Small bowel obstruction due to phytobezoar: CT diagnosis. Eur Radiol. 2002;12:2659e26561. 8. Escamilla C, Robles-Campos R, Parrilla-Paricio P, et al. Intestinal obstruction and bezoars. J Am Coll Surg. 1994;179:285e288. 9. Zissin R, Osadchy A, Gutman V, et al. CT finding in patients with small bowel obstruction due to phytobezoar. Emerg Radiol. 2004;10:197e200. 10. Stemberg A, Coscas D, Fireman Z. Gastric phytobezoar. Harefuah. 1996;130: 316e319. 11. Frager D, Medwid SW, Jw Baer, et al. CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause. Am J Roentgenol. 1994;162:37e41. 12. Maglinte DD, Gage SN, Harmon BH, et al. Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology. 1993;188:61e64. 13. Quiroga S, Alvarez-Castells A, Sebastia MC, et al. Small bowel obstruction secondary to bezoar: CT diagnosis. Abdom Imaging. 1997;22:315e317. 14. Gayer G, Jonas T, Apter S, et al. Bezoars in the stomach and small bowel: CT appearance. Clin Radiol. 1999;54:228e232. 15. Tan KB, Premasiri MK, Isaac J, et al. Mushroom bezoar: a rare cause of small intestinal obstruction. Pathology. 2004;36:207e208. 16. Arnal-Etienne S, Puttemans T. Small bowel obstruction due to a mushroom bezoar. JBR-BTR. 2009;92:114.