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Table of Contents
CASE SERIES
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 196-198

Bezoar: An unusual cause of acute surgical abdomen


Department of General and Minimal Access Surgery, Government Medical College, Jammu and Kashmir, India

Date of Submission10-Jul-2021
Date of Decision08-Aug-2021
Date of Acceptance12-Aug-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Yaqoob Hassan
Skims Medical College, Department of General Surgery, Boys Hostel, Room NO. F7, Srinagar, Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_45_21

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  Abstract 


Rationale: Small bowel obstruction by bezoars is an infrequent entity encountered in general surgical practice. Early diagnosis and management are paramount to prevent the development of drastic complications. Patient concerns: Bezoar in general and rubber-band-bezoar in particular is an extremely rare case of mechanical small bowel obstruction. We report two cases of bezoar presented as acute surgical emergency in children. A brief review in the context is also presented. Diagnosis: Clinical examination, biochemical parameters and imaging studies showed features of compete small bowel obstruction. Interventions: One patient had bezoar of rubber-bands in the distal ileum and removed via enterotomy. The second had two trichobezoars one in ileum and another in stomach and underwent enterotomy and gastrotomy. Outcomes: Both our patients had uneventful intra-operative period and post-operative recovery and are on regular follow-up. Lessons: Bezoar-induced small bowel obstruction with acute presentation remains a rare diagnosis particularly in children. Accurate pre-operative diagnosis is notoriously difficult and operative intervention remains a rule. High clinical suspicion and proper radiological work-up is necessary to reach a definitive diagnosis.

Keywords: Bezoar, acute abdomen, children


How to cite this article:
Ahmad F, Hassan Y. Bezoar: An unusual cause of acute surgical abdomen. Hamdan Med J 2021;14:196-8

How to cite this URL:
Ahmad F, Hassan Y. Bezoar: An unusual cause of acute surgical abdomen. Hamdan Med J [serial online] 2021 [cited 2022 Jan 20];14:196-8. Available from: http://www.hamdanjournal.org/text.asp?2021/14/4/196/335381




  Introduction Top


Intestinal obstruction is one of the leading emergencies encountered in general surgical practise that needs effective management. Depending upon the nature of the cause, obstruction can be dynamic (mechanical) or adynamic (functional). The dynamic is defined in which peristalsis is working against mechanical obstruction. The aetiologies of dynamic obstruction can be classified into intraluminal, intramural or extramural causes and can be acute or chronic. Post-operative adhesion is the most common cause and accounts for about 40%–60% of cases of intestinal obstruction.[1] Others include stricture, malignancy, bezoars, intussusception, hernias and gallstones. A bezoar is a foreign body composed of undigested material trapped in the gastrointestinal tract and depending upon composition can be phytobezoar (vegetable fibre matter), trichobezoar (hair), lactobezoar (concentrated milk formulas), food bolus bezoars and others. Intestinal obstruction in children secondary to bezoars is extremely rare and poses a diagnostic challenge for a general surgeon working in the accident emergency department. The small-bowel obstruction (SBO) secondary to bezoar impaction is less common, with a reported frequency around 0.4%–4%.[2] Lactobezoars commonly affect infants, whereas trichobezoars are usually found in young girls who suck, chew and swallow their own hair. Although bezoar can affect anyone, some health conditions may indicate the increased likelihood of bezoars such as patients with previous gastric surgeries, pyloroplasty, abnormal chewing, diminished gastric secretion and motility and hypothyroid and neuropathic patients. The incidence of bezoars in post-gastrectomy patients ranges between 5% and 12%.[3] The accurate pre-operative diagnosis is difficult, due to lack of specific symptoms, and in patients with complete obstruction, operative diagnosis is the rule rather than the exception. Only 1.1% of patients present with bezoar-induced SBO with an acute surgical abdomen.[4] We hereby present an unusual case series of small intestinal obstruction: one caused by a rubber band bolus and another by trichobezoar. Both our patients were in sound state of health without any significant past medical or surgical history.


  Case Details Top


Case 1

A 12-year-old male child, with no significant past medical and surgical history, presented with 5-day complaints of pain abdomen, progressive distension and bilious vomiting. The pain was initially colicky in nature and progressed to constant type. On clinical examination, the patient was dehydrated and anxious with a pulse rate of 112 bpm, blood pressure (BP) of 100/50 mmHg, respiratory rate of 22 breaths/min and temperature of 100°F. The abdomen was distended with visible gut loops, tender and guarded, and on auscultation, bowel sounds were absent. On digital rectal examination, the rectum was empty and ballooned out and the finger got stained with mucus. The patient was resuscitated with Ringer's lactate intravenous fluids and blood samples taken for baseline investigations [Table 1]. As a first radiological investigation, radiograph and ultrasonography abdomen were performed. Radiograph abdomen showed multiple air-fluid levels and dilated small gut loops and ultrasonography showed dilated small gut loops with the largest diameter of 3.5–4 cm and interloop fluid. In view of clinical features of peritonism and raised lactate levels, the patient was decided for surgical intervention. After explaining the procedure details, side effects and associated complications to the parents of the patient, informed consent was taken and the patient was shifted to the emergency operation theatre.
Table 1: Biochemical-haematological parameters

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The procedure was done under general anaesthesia. Right upper transverse incision was made and meticulously deepened to the general peritoneal cavity. Intraoperatively, the small-bowel loops were grossly dilated and oedematous extending from the duodenojejunal junction to the distal ileum approximately 50 cm from the ileocaecal junction. No features of any gangrenous change were noticed. A palpable, firm intraluminal mass was present in the distal ileum. A 2-cm long enterotomy was made on the antimesenteric border proximal to the site of obstruction and foreign body was retrieved en masse [Figure 1]. The enterotomy wound was closed with Vicryl 3-0 and silk 3-0 in two layers. The rest of the small gut and stomach was examined for any concomitant bezoar. The abdomen was closed back in layers, and antiseptic dressing was applied. The foreign body was dissected on operating table and showed bunch of rubber bands entangled with each other. Two sizes of bands were found small and larger one with a total count of 60 [Figure 1]. Postoperatively, the patient made uneventful recovery and was discharged on the 5th day of surgery. The patient is doing well 3-month post-surgery and is on regular follow-up.
Figure 1: Operative photographs of Case 1

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Case 2

An 11-year-old girl with previous childhood history of craving for clay, soil and hair, referred from a peripheral health centre with 2-day history of illness, presented with symptoms of abdominal pain, vomiting and constipation. On clinical examination, the patient was sick looking, dehydrated and anxious. Her abdomen was moderately distended and tender with palpable masses: one in the epigastrium and another in the right periumbilical region. Bowel sounds were exaggerated. She had a blood pressure of 100/56 mmHg, a pulse rate of 122 beats/min, a respiratory rate of 20 breaths/min and a body temperature of 100.2°F. The laboratory evaluation revealed a white blood cell count of 18.1 thousands/dl with 95% neutrophils, a haemoglobin of 11 mg/dL and a platelet count of 175 thousands/dl, lactate acid level of 2.5, Na of 135 mEq/dL and K of 2.9 mEq/dL. Kidney function tests were normal. Radiograph and ultrasonography abdomen showed features of obstruction. Radiograph showed suspicious opacity in the small intestine. Ultrasonography also showed the hyperechoic lesion: one in the small gut lumen about 8 cm × 2 cm in size and another in the stomach (10 cm × 3 cm in size). The patient was taken for emergency laparotomy after informed written consent from parents. At laparotomy, a trichobezoar was found impacted 45–50 cm from the ileocaecal valve, causing complete intestinal obstruction. The mass was firm and removed through 2-cm distal enterotomy as it was not feasible to be fragmented and milked into the caecum [Figure 2]. Another palpable intragastric hard bezoar was removed through gastrostomy [Figure 2]. Both the enterotomy and gastrostomy sites were closed back in two layers. The rest of the gut was meticulously examined for any concomitant bezoars and was unremarkable. Post-operative course was uneventful except minor superficial wound site infection which was managed conservatively. She was discharged on the 7th post-operative day and attached to our outpatient department for follow-up. The patient is doing well and asymptomatic 10-month post-surgical period.
Figure 2: Intraoperative pictures of Case 2

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  Discussion Top


A bezoar is a tightly packed mass of undigested or partially digested material in an alimentary tract. Most of the patients remain asymptomatic or can have mild episodic symptoms of abdominal pain, nausea, vomiting, anaemia, loss of appetite and early satiety. Normally, stomach remains the most common site of bezoar formation but can migrate to distal bowel and procedure symptoms.[5] 0.4%–4% of patients present with SBO and 1.1% present with acute surgical abdomen.[2],[4] Although, bezoars can form in individuals of any sex and age with higher incidence in patients of previous gastric surgery, incomplete mastication secondary to poor dentition and prolonged stasis due to Crohn's disease, tuberculosis and gastrointestinal diverticula.[6] Phytobezoars are the most common, composed of vegetable matter and generally affect old adults, whereas trichobezoars have hair contents and usually present in individuals with psychiatric illness or mental retardation. Lactobezoars affect infants with dehydration, prematurity and low birth weight (an immature gastrointestinal tract) and consumption of high-calorie formula and addition of thickening agents in the 1st week of life.[7]

The diagnosis of bezoar-induced SBO is very difficult and needs high clinical suspicion and proper radiological work-up to discharge a definitive diagnosis. Plain radiography of the abdomen in standing and supine position is the early investigation to confirm the SBO. An upright plain radiography of the abdomen may show the triad of dilated small bowel loops (>3 cm in diameter), air fluid levels and paucity of air in colon. The sensitivity of abdominal radiographs in the detection of SBO ranges 70%–80%.[8] Computed tomography is 80%–90% sensitive and 70%–90% specific in the detection of SBO [8] and its role in diagnosis SBO secondary to bezoar, have been documented in the literature.[6],[9] In a systematic review by Gottlieb et al., ultrasound was found to be 92.4% sensitive and 96.6% specific for SBO.[10]

Surgical treatment remains the treatment of choice in bezoar-induced SBO and includes laparotomy and milking of offending agent into caecum or performing enterotomy in difficult patients. Laparoscopy is safe and effective in the management of bezoar-induced SBO and is associated with lower morbidity as compared with the conventional open approach.[11] We present two uncommon cases of bezoar obstruction presented as acute abdomen in our emergency department. The peculiarity of patients in our study was that both the subjects were absolutely normal without any significant past medical, surgical or mental illness.


  Conclusion Top


Bezoar-induced SBO with acute presentation remains a rare diagnosis, particularly in children. Accurate pre-operative diagnosis is notoriously difficult, and operative intervention remains a rule. High clinical suspicion and proper radiological work-up is necessary to reach a definitive diagnosis. Patients with underlying psychiatric illness should be attached to proper counselling centres, and emphasis should be made to prevent the recurrence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients' legal guardians have given their consent for images and other clinical information to be reported in the journal. The patients' guardians understand that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Williams N, O'Connell PR, McCaskie A. Intestinal obstruction. In: Bailey & Love's Short Practice of Surgery, 27th Edition: The Collector's Edition. Ch. 71. Boca Raton, FL: CRC press; 2018. p. 1301–19. https://doi.org/10.1201/9781315111087.  Back to cited text no. 1
    
2.
Erzurumlu K, Malazgirt Z, Bektas A, Dervisoglu A, Polat C, Senyurek G, et al. Gastrointestinal bezoars: A retrospective analysis of 34 cases. World J Gastroenterol 2005;11:1813-7.  Back to cited text no. 2
    
3.
Acar T, Tuncal S, Aydin R. An unusual cause of gastrointestinal obstruction: Bezoar. N Z Med J 2003;116:U422.  Back to cited text no. 3
    
4.
Bedioui H, Daghfous A, Ayadi M, Noomen R, Chebbi F, Rebai W, et al. A report of 15 cases of small-bowel obstruction secondary to phytobezoars: Predisposing factors and diagnostic difficulties. Gastroenterol Clin Biol 2008;32:596-600.  Back to cited text no. 4
    
5.
Escamilla C, Robles-Campos R, Parrilla-Paricio P, Lujan-Mompean J, Liron-Ruiz R, Torralba-Martinez JA. Intestinal obstruction and bezoars. J Am Coll Surg 1994;179:285-8.  Back to cited text no. 5
    
6.
Kim JH, Ha HK, Sohn MJ, Kim AY, Kim TK, Kim PN, et al. CT findings of phytobezoar associated with small bowel obstruction. Eur Radiol 2003;13:299-304.  Back to cited text no. 6
    
7.
Andrus CH, Ponsky JL. Bezoars: Classification, pathophysiology, and treatment. Am J Gastroenterol 1988;83:476-8.  Back to cited text no. 7
    
8.
Maglinte DD, Heitkamp DE, Howard TJ, Kelvin FM, Lappas JC. Current concepts in imaging of small bowel obstruction. Radiol Clin North Am 2003;41:263-83, vi.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. Am J Emerg Med 2018;36:234-42.  Back to cited text no. 10
    
11.
Yau KK, Siu WT, Law BK, Cheung HY, Ha JP, Li MK. Laparoscopic approach compared with conventional open approach for bezoar-induced small-bowel obstruction. Arch Surg 2005;140:972-5.  Back to cited text no. 11
    


    Figures

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    Tables

  [Table 1]



 

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