Phytobezoar

Case contributed by Dr Prat-Matifoll

Presentation

76 year-old patient who referes subacute abdominal pain. Past medical history did not include any significant past diseases or surgeries.

Patient Data

Age: 76
Gender: Female
X-ray

Dilated small bowel loops filled with endoluminal contrast media. Note the sudden stop in the hypogastrium, probably the cause of obstruction is at this level.

CT

Intraluminal debris containing air bubbles (red arrow, mottled appearance) at the site of the obstruction, in the hypogastrium.

Note the dilated small bowel loops (yellow arrow) before the previously described intraluminal debris as well as the normal bowel loops after them (green arrow).

The length of the feces-like material is the key for differentiating faeces-sign from bezoar. Up to 5 cm in length may be regarded as an obstructing phytobezoar (blue arrow). 

CT

Note the intraluminal filling defect with endoluminal contrast mixing with the admixture of gas bubbles and non-digested food (phytobezoar),  giving a "mottled appearance" (red arrow).

Case Discussion

A bezoar is a concentration of ingested material within the gastrointestinal tract. Trichobezoars (hair) and phytobezoars (poorly digested fibers, seeds, fruits)  are the two most common types. 

Phytobezoars are formed within the stomach in patients with predisposing factors (gastric surgery, inadequate chewing, gastroparesis). After gastric surgery or diabetic gastroparesis, stomach may empty rapidly to small intestine and gastric acidity may decrease, increasing the likelihood of bezoar formation.

Imaging

Plain abdominal film: Intraluminal filling defect with barium filling the phytobezoar, giving a "mottled appearance".

CT scan: Intraluminal debris containing air bubbles  ("mottled appearance") and location at the site of the obstruction. Sometimes, it is difficult to differentiate phytobezoar impaction and small-bowel faeces sign in patients with SBO. 

The length of the feces-like material is the key for differentiating faeces -sign from bezoar. An ovoid mass containing air-bubbles up to 5 cm in length may be regarded as an obstructing phytobezoar.

Treatment

The treatment of small bowel obstruction caused by a bezoar is surgical (fragmentation and milking of the bezoar or enterotomy). Gastric exploration is also indicated to rule out concomitant gastric bezoar. In our case, surgeons decided to "milk" the bezoar from the ileum (100 cm) to the ileocecal valve without performing an enterotomy.

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Case information

rID: 47839
Case created: 5th Sep 2016
Last edited: 7th Sep 2016
Inclusion in quiz mode: Excluded

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