Large Bowel Obstruction Secondary to a Colonic Bezoar: A Case Report

Abstract

Purpose: Bezoars are a rare result of ingestion of poorly digestible or indigestible materials. Predisposing factors include inadequate chewing, poor dental health, excessive consumption of certain foods or previous gastric surgery. While most bezoars are found in the stomach and small intestine, colonic bezoars are unusual and infrequently described in the literature. We present a case of large bowel obstruction due to a bezoar, which required definitive surgery. A 44 year old male with history of diabetes mellitus and pancreatic neuroendocrine tumor with metastasis requiring pancreaticoduodenectomy with en bloc segmental transverse colectomy 8 months prior presented with fever and 2 day history of abdominal pain, nausea, and vomiting. Lab studies revealed mildly elevated liver enzymes (alkaline phosphatase 260 IU/L, AST 43 IU/L, ALT 75 IU/L), a white blood cell count of 13.6 × 109/L, and hypoalbuminemia (2.4 g/dL). Recent serum chromogranin A was normal. CT scan showed a well-defined mass of mixed density and stool within the hepatic flexure. There was marked dilation extending to the transverse colon, but the distal colon was normal. Abdominal ultrasound was negative. Empiric antibiotics were initiated. Colonoscopy was performed to the mid-transverse colon which revealed a bezoar characterized by seeds, fibers, and fibrous material obstructing the lumen (Figure 1). This was partially broken up with forceps and a Roth net. Patchy necrosis of the bowel wall without evidence of stricture or narrowing was seen. The patient developed hypotension, thus the scope was withdrawn. An abdominal film disclosed no free air. Subsequent exploratory laparotomy with right hemicolectomy was performed. Pathology demonstrated ulcerated and partly necrotic colon extending from the ileocecal valve to the prior anastomosis with near perforation. The patient had an uncomplicated postoperative course. We demonstrate a unique case of a colonic bezoar causing large bowel obstruction and pressure necrosis that was successfully treated with surgery. The cause is likely multifactorial, given our patient's history of diabetes and previous colon operation. Conservative management includes enemas and manual disimpaction, however, in cases with life threatening complications prompt surgery is required.Figure 1