Gastric and intestinal phytobezoar with incomplete intestinal obstruction
Presentation
Abdominal pain and distension. The pain was intermittent and relieved by analgesics
Patient Data
Initial non-enhanced CT study
Non- enhanced CT study shows moderate dilatation of the stomach with intraluminal two gas-containing ovoid bodies initially presumed to be food residues. Moderate dilatation of the small bowel loops with another similar gas- containing ovoid body seen intraluminal within an ileal loop (review annotated images). Mild intraperitoneal free fluid is also noted
The patient followed conservative treatment with stationary intermittent pain and distension. He passed profuse watery diarrhea. Due to stationary symptoms, further contrast-enhanced CT was done.
FU contrast-enhanced CT...
FU contrast-enhanced CT study after 2 days
Contrast-enhanced CT study shows the same findings noted in the previous study with still visualized intragastric and ileal gas containing bodies. The previous consideration of food residues is now questionable. A confusing collapsed bowel loop cluster at the left para duodenal region is also noted
The patient still under conservative treatment. NGT was inserted however the pain is still present and distension is stationary. Follow up non-enhanced CT was done
FU NCCT after 2 days
Follow up non-enhanced CT study shows stationary gastric and small bowel dilatation with intra-gastric questionable bodies. The ileal mass-like body moved to the left iliac fossa.
The patient's clinical status became worse and the imaging findings were not definite. The multidisciplinary team decided exploratory laparotomy
Intra-operative
Intraoperative: multiple gastric and small bowel semi-soft foreign bodies were found, removed, and sent for histopathology that revealed:
Specimen Type: Foreign bodies
Clinical History: Intestinal obstruction by foreign bodies
Macroscopic: Specimen received without formalin with patient identification and file number and labeled as, intestinal foreign bodies, consisting of 4 pieces of abnormal foreign bodies, semi-soft, greenish colored, each measuring about 5x5x3cm. The cut section reveals yellowish friable tissue.
Microscopic: Sections show material of plant origin with no evidence of malignancy.
Diagnosis: Intestinal obstruction by foreign bodies, removed for biopsy. Foreign bodies of plant origin with no evidence of malignancy.
Annotated images highlight gastric and intestinal phytobezoars in the initial (red color), first follow up (yellow color), and last follow up (green color) CT studies
Case Discussion
Bezoar refers to special food or foreign body that is not digested in the alimentary tract with subsequent conglomeration and formation of mass-like lesions that are occasionally causing gastric /intestinal obstruction. It may be of plant"phytobezoar", hair "trichobezoar" or drug "pharmacobezoar" nature.
Intraluminal pathologies should be considered while searching for the cause of intestinal obstruction. However, suspicion of phytobezoar is occasionally difficult on imaging especially if small and multiple due to the great similarity to food residues and particles in addition to unhelpful clinical history, as it is just undigested food compared to trichobezoar and pharmacobezoar where the clinical history is often helpful. Stationary visualization of these bodies on follow-up imaging may be a helpful clue however the degree of confidence occasionally remains low.
Intraoperative photos contribution by Dr/ Adel Abdelwahed