Small Bowel Obstruction Secondary to a Mushroom Bezoar

Abstract

To the Editor: Small bowel obstruction (SBO) is a common presentation in any emergency department (ED). Small bowel obstruction secondary to bezoar impaction is considerably less common, with a reported frequency of approximately 4%,1 and is rarely diagnosed preoperatively. Bezoars are concretions of indigestible matter in the gastrointestinal tract and usually occur in individuals with mental retardation or delayed gastric emptying. They may be associated with gastrointestinal obstruction.2 A 70-year-old man with medical history of cerebrovascular accident, chronic pulmonary obstructive disease, and hypertension was sent to the ED because of progressive abdominal distension with vomiting for 3 days. He denied having undergone any gastric surgery. On arrival in the ED, his vital signs were normal except for a pulse rate of 110 beats per minute. Physical examination revealed diffuse abdominal tenderness with mild rebound tenderness. Abnormal laboratory findings were as follows: white cell count 15.92 × 109/L, C-reactive protein 4.21 mg/dL, blood urea nitrogen 77 mg/dL, and serum creatinine 2.69 mg/dL. Abdominal radiograph revealed dilated loops of small bowel, with air and fluid levels suggesting intestinal obstruction. He underwent contrast-enhanced computed tomography (Figure 1A) at the level of the lower abdomen, which revealed a well-circumscribed, round, intraluminal mass in the proximal ileum (arrow). A close-up view (Figure 1B) showed the mass with a mottled gas pattern outlined by small bowel fluid (arrow) consistent with bezoar impaction. He underwent emergency exploratory laparotomy after failure of a series of conservative treatments such as nasogastric decompression, intravenous fluids, and antibiotics. The bezoar was composed of an undigested mushroom. The postsurgical period was complicated by aspiration pneumonia, septic shock, and multiorgan failure. The patient died 12 days after admission despite aggressive management. Bezoars may be encountered in infants because of ingestion of indigestible materials. In older children and adults, bezoars can be seen together with gastric emptying problems (e.g., due to diabetic gastroparesis, hypothyroidism, drugs), previous gastric surgery (vagotomy, gastrectomy, gastroenterostomy), dental problems, abnormal mastication, or a history of high fiber intake (e.g., persimmons, figs, citrus fruits, bananas).3, 4 In one case, the authors speculated that use of dentures contributed to poor chewing of food, increasing the possibility of phytobezoar formation,5 as in the current case. Bezoars often form in the stomach, but after fragmentation, they may migrate into the small bowel and lead to mechanical obstruction, so small bowel bezoars are often found in association with gastric bezoars.4 In one study, the incidence of mechanical SBO secondary to phytobezoar was 8.5%,6 which is higher than a previous report of 4%.1 This difference may have been because their study was conducted in the winter, the season of persimmon production in Taiwan.6 In a retrospective study, the symptoms of a gastrointestinal bezoar were epigastric or generalized abdominal pain in all cases, mild to severe nausea and vomiting in 33 cases (97.0%), and abdominal distention as a sign of intestinal obstruction in 16 cases (47.0%).3 The radiology literature includes few reports of small bowel bezoars, but the computed tomography findings are characteristic, and this technique permits rapid and accurate diagnosis of the problem. An intraluminal mass with a mottled gas pattern is at the site of obstruction, and abrupt luminal collapse beyond the lesion is diagnostic for small bowel bezoar.7 Surgery is needed when bezoars cannot be removed endoscopically or when they cause mechanical obstruction, but surgery for bezoars has significant morbidity and mortality, especially in older adults and in individuals with comorbid diseases.8 In conclusion, bezoar-induced SBO should be included in the differential diagnosis of abdominal pain in older adults, even when there is no apparent predisposing factor for bezoar formation. It remains a diagnostic and management challenge and can occur in the absence of any gastric surgery, which was the case with this individual. Surgical intervention is the standard management for an intestinal bezoar, and early diagnosis and intervention reduce morbidity and mortality, especially in older adults with multiple comorbidity. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Concept and design: Ho, Cheung. Acquisition of subject and data: Chou, Ho. Analysis and interpretation of data: Ho, Chou, Cheung. Preparation of manuscript: Ho, Cheung. Critical review and approval: All authors. Sponsor's Role: None.