Bezoar-induced Small Bowel Obstruction Research Articles

Small bowel obstruction due to a meat bolus bezoar: the second case report in literature

Introduction: Small bowel obstruction is a difficult emergency condition that may be caused due to many factors. However, bezoar-induced small bowel obstruction accounts for only 0.4–4.8% of all intestinal impaction patients. Bezoars are an entity of undigested materials classified into four types: phytobezoar, trichobezoar, pharmacobezoar, lactobezoar. Meat bolus bezoar is not named under any of these classifications. Case presentation: A 75-year-old man presented with abdominal distention, vomiting, and constipation. On radiological imaging, a mass in the terminal ileum was detected. After 2 days of ineffective conservative therapy, the authors decided to perform an open surgery. Enterotomy approach was chosen after failing to milk the object into the colons. The foreign body impacting the bowels was identified as a meat bolus bezoar. The patient improved after the surgery. The authors recorded no recurrence or complications with our patient after 18 months of follow-up. Discussion: Patients with small bowel obstruction usually present with acute abdominal pain and distension despite the blockage cause. Computed tomography is the most effective diagnostic tool in such cases. In bezoar-induced intestinal blockage, surgical management is mandatory if conservative therapy fails. Conclusion: It is important to consider bezoar-induced small bowel obstruction as a potential cause of impaction in cases of acute abdominal pain accompanied with risk factors of bezoar formation, despite the bezoar type.

Khat induced bezoar; a rare cause of small bowel obstruction:a case report.

IntroductionBezoar-induced small bowel obstruction (sbo) is a rare entity that might be difficult to establish diagnosis preoperatively. There are a multitude of factors attributed to its occurrence in different literature. Khat chewing which is widely practiced in eastern African and Middle East countries might contribute directly or indirectly to bezoar formation. It has chemicals known to decrease bowel motility thereby, possibly leading to concretion of proximal gastrointestinal contents. The aim of this case report is to give emphasis on the effect of khat towards bezoar formation as a result of alteration in bowel motility.Case presentationThis is the case of a 60 years old farmer presented to our Hospital complaining Periumbilical abdominal pain of 3 days duration. He had the cardinal symptoms of obstruction. Historically he used to have intermittent episodes of constipation, otherwise no similar attack before. His staple diet was porridge made of wheat flour mixed with cooked and crushed potato along with cabbage consumed twice a day. He regularly chews Khat, a green leaf which has different chemicals known to have stimulant effect and cause decreased bowel motility.DiscussionThere are diverse reasons behind bezoar formation that cause bowel obstruction; out of which a preoperative diagnosis is made for few. The attributing factors were known retrospectively for majority of the cases but others remain speculations with different scientific reasoning.In our case, almost the main risk factors incriminated in the causation of bezoar formation and bowel obstruction were assessed with no supportive evidence other than khat associated constipation which has normalized after chewing khat was stopped. Additionally, tannin, an extract of khat polymerizes in an acidic environment to form a glue-like coagulum which can affix to other materials in the stomach that predisposed to bezoar formation.ConclusionIn patients having features of small bowel obstruction, complaining chronic constipation and who has regular khat chewing habit has to be suspected to have a bezoar as a cause. Bowel motility improves upon stopping chewing khat which may help decrease the recurrence of bezoar formation.

S2257 Colonoscopic Decompression of a Bezoar-Induced Small Bowel Obstruction

S2257 Colonoscopic Decompression of a Bezoar-Induced Small Bowel Obstruction

Clinical characteristics and indications for surgery for bezoar-induced small bowel obstruction.

BackgroundTo evaluate the clinical characteristics and indications for surgery for bezoar-induced small bowel obstruction (BI-SBO).MethodsForty patients with BI-SBO were treated at our hospital from January 2017 to December 2019, and these patients’ clinical and computed tomography (CT) data were analyzed.ResultsTwenty-seven and 13 BI-SBO patients constituted the non-ST group and ST group, respectively. The clinical manifestations of BI-SBO in both groups were abdominal pain, nausea, vomiting, and lack of defecation. Comparing the non-ST vs ST groups, respectively: mean age (years): 63.15 ± 16.15 vs 60.38 ± 12.47; duration of symptoms (hours): 55.11 ± 44.08 vs 59.33 ± 72.90; mean bezoar length (cm): 5.31 ± 0.74 vs 3.72 ± 0.53; mean bezoar width (cm): 3.74 ± 0.48 vs 2.9 ± 0.64; bezoar CT maximum Hounsfield units (HU): 97.23 ± 12.36 vs 21.11 ± 7.27; total hospital stay (days): 5.56 ± 4.23 vs 7.12 ± 6.12 (mean: 8.62 ± 2.81); and total hospitalization costs (RMB): 6378.02 ± 3015.68 vs 8213.71 ± 5564.29. Mean operation time was 85.00 ± 8.90 minutes, and mean operation blood loss was 32.31 ± 19.64 mL. Bezoars were located 60 to 160 cm from the ileocecal junction. Univariate analysis demonstrated that bezoar length and width and maximum CT value were significant risk factors for surgery.ConclusionLarge bezoar size and high CT values may be indications for surgery. Surgery is necessary and effective when nonsurgical treatment is ineffective.

Bezoar: An unusual cause of acute surgical abdomen

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.

Diagnosis of Bezoar-induced small-bowel obstruction on sonography in emergency department

Bezoars are defined as indigestible foreign materials impacting in the gastrointestinal tract, which are classified according to what they are composed of. Small intestinal obstruction caused by bezoar impaction was a rare disease. However, it has become more and more recognized since gastrectomy with truncal vagotomy was introduced into the treatment of peptic ulcer disease. Computerized tomography (“CT”) is still the imaging modality of choice in preoperative diagnosis of small bowel obstruction caused by bezoars. Although ultrasound has less sensitivity and specificity in detecting bezoars as compared with CT, it still can reveal bezoars in 88% of patients. Some case reports have addressed the role of sonographic detection of small intestinal phytobezoar. Ultrasonography may be a more available and time saving tool when used as a “screening” modality at emergency department for patients with mild persistent nonspecific abdominal pain but without definite peritoneal signs, especially when presence of past history of gastrectomy with truncal vagotomy.

Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature

Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient's history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone.

An Unusual Case of Small Bowel Obstruction

Small bowel obstruction is a general surgical emergency usually caused by adhesions or herniae. Malignancy, inflammatory bowel disease and ingested foreign bodies (bezoars) are rarer causes. Bezoars can occur at any point in the gastrointestinal tract (GIT) depending on the type of bezoar and the point of impaction. Abdominal CT scan can assist in making an accurate and timely diagnosis of bezoar-induced small bowel obstruction. Bezoar-induced acute bowel obstruction requires either endoscopic or surgical extraction to avoid the complications of hemorrhage, perforation or fistula formation. J Med Cases. 2015;6(11):517-519 doi: http://dx.doi.org/10.14740/jmc2343w

Bezoar-induced small bowel obstruction: Clinical characteristics and diagnostic value of multi-slice spiral computed tomography.

To determine the possible predisposing factors of bezoar-induced small bowel obstruction (BI-SBO) and to discuss the diagnostic value of multi-slice spiral computed tomography, particularly contrast-enhanced scanning, in this condition. A total of 35 BI-SBO cases treated at our hospital from January 2007 to December 2013 were retrospectively analysed. Complete clinical and computed tomography (CT) data of the patients were available and confirmed by surgery. SBO was clinically diagnosed on the basis of clinical manifestations. Of the 35 patients, 18 underwent abdominal and pelvic CT planar scanning with GE 64-slice spiral CT and 17 underwent abdominal and pelvic CT planar scanning with GE 64-slice spiral CT combined with contrast-enhanced examination. Original images were processed using a GE ADW4.3 workstation to obtain MPR, CPR, MIP and CTA images. The images of all patients were evaluated by two abdominal imaging experts. The main analytical contents of planar scanning included intestinal bezoar conditions, changes in the intestinal wall and changes in peri-intestinal conditions. Vascular hyperaemia and arterial blood supply conditions at a specific obstruction site and the distal end of the obstruction site were evaluated through contrast-enhanced examination. The proportion of males to females among the 35 cases was 1:1.69 (13:22); median age was 63.3 years. The following cases were observed: 29 (82.8%) cases occurred in autumn and winter and showed a history of consuming high amounts of persimmon and hawthorn; 19 (54.3%) cases revealed a history of gastrointestinal surgery; 19 exhibited incomplete dentition, with missing partial or whole posterior teeth; 26 suffered from obstruction at the ileum. A total of 51 bezoars were found in these patients, of whom 16 (45.7%) had multiple bezoars. CT planar scanning of bezoars showed lumps with mottled gas inside the intestinal cavity. Furthermore, 9 cases of bezoars had envelopes and 11 cases were accompanied with thickening of the distal wall of the obstructed bowel. Scanning of 17 cases was enhanced; the results revealed that the mesenteric blood vessels at the obstruction site and the proximal site were dilated, and a total of 7 cases were accompanied with distal vascular dilation and intestinal wall thickening. BI-SBO exhibits regional and seasonal characteristics. CT planar and contrast-enhanced scanning can be applied to diagnose and observe vascular conditions in obstructed zones.

Bezoar: An unusual cause of intestinal obstruction

Aim-Background This article presents three cases of bezoar-induced small bowel obstruction (SBO). An uncommon entity, gastrointestinal bezoar (GIB) is reported to occur in 4% of all admissions for small bowel obstruction (SBO), with a prevalence in patients with a history of gastric surgery. Accurate preoperative diagnosis is notoriously difficult, and conventional management often necessitates laparotomy. Most bezoars are concretions of poorly digested food, which are usually formed in the stomach initially. Owing to their lack of diagnostic features, bezoars are often associated with delayed treatment and increased morbidity.

Small Bowel Obstruction Secondary to a Mushroom Bezoar

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.

Bezoar-induced Small Bowel Obstruction

PurposeThe aim of this study was to observe the clinical features of a bezoar-induced small bowel obstruction and to investigate the role of abdominal computed tomography (CT) in establishing the diagnosis.MethodsWe retrospectively reviewed 20 cases of bezoar-induced small bowel obstruction in our hospital from 1996 to 2010.ResultsThirteen patients (65%) had a history of abdominal surgery. Nine patients (45%) were diagnosed with a bezoar before surgery, seven patients were diagnosed by using abdominal CT, and two patients were diagnosed with a small bowel series. Abdominal CT was performed in 15 patients, and the diagnostic accuracy was 47% (7/15). Surgery revealed ten bezoars in the jejunum and 11 in the ileum. Two patients had bezoars found concurrently in the stomach. Spontaneous removal took place in two patients. An enterotomy and bezoar extraction was performed in 15 patients. Fragmentation and milking, a small bowel resection, and a Meckel's diverticulectomy were performed in one patient each. Early operative treatment was possible (P = 0.036) once the bezoar had been diagnosed by using abdominal CT. There tended to be fewer postoperative complications in patients who were diagnosed with a bezoar by using abdominal CT, but the result was not statistically significant (P = 0.712).ConclusionA preoperative diagnosis of bezoar-induced small bowel obstruction by using clinical features was difficult. Increased use of abdominal CT led to a more accurate diagnosis and to earlier surgery for bezoar-induced small bowel obstructions, thereby reducing the rate of complications.

Small Intestinal Obstruction Caused by a Bezoar in an Elderly Patient

Small bowel obstruction caused by phytobezoars is quite uncommon in patients suffering from acute abdomen. The most common causes of small bowel obstruction are adhesive bands, incarcerated hernia, and adjacent tumor. We present a rare case of phytobezoar-induced small bowel obstruction in a female elderly patient without a history of abdominal surgery. An 83-year-old female presented to our emergency department on 5 March 2008 with intermittent vomiting and abdominal pain. After failure of conservative treatment with nasogastric tube decompression and a prokinetic agent, abdominal computed tomography (CT) with contrast was arranged on March 9, 2008. The CT scan showed marked dilatation of the jejunum with fluid retention and possibly a large calcified bezoar (2.7cm × 3.16cm) causing obstruction at the ileum. Surgery was performed on March 13, 2008, and the pathologic report showed a fibrocalcified nodule. Based on this case, we have suggest that bezoar-induced small bowel obstruction remains possible even in patients with no history of gastric surgery, autonomic enteropathy, or recent intake of persimmons. Surgical intervention is the standard management for intestinal bezoars, and early diagnosis and intervention reduces morbidity and mortality.

Laparoscopic Treatment of Bezoar-induced Small Bowel Obstruction: Report of a Case

Treatment of bezoar-induced intestinal obstruction is usually performed by an open approach, with either digital fragmentation or removal of the bezoar via enterotomy. Laparoscopy is gaining increased acceptance for diagnosis and treatment of selected cases of small bowel obstruction. We describe a 77-year-old male patient with small bowel obstruction, and the cause of intestinal obstruction was proved by diagnostic laparoscopy to be a bezoar, which was fragmented and milked into the colon smoothly with laparoscopic instruments. The patient had an uneventful recovery and was discharged from the hospital 4 days later after the procedure. A review of the literature shows that laparoscopic management is an alternative to conventional surgery, either by a totally laparoscopic approach or a laparoscopic-assisted procedure. Minimally invasive surgery is not only an excellent diagnostic tool for bezoar-induced small bowel obstruction, but also in some selected cases, a choice of treatment.

Small‐Bowel Obstruction Secondary to Bezoar Impaction: A Diagnostic Dilemma

Gastrointestinal bezoar (GIB) is uncommon and is reported to occur in 4% of all admissions for small-bowel obstruction (SBO). Because of a lack of diagnostic features, it is often associated with a delay in treatment, with increased morbidity. In this article, we report our experience with managing bezoar-induced SBO and the role of early computed tomography (CT) imaging in establishing the diagnosis. We retrospectively reviewed all cases of bezoar-induced SBO treated in our unit between 1999 and 2005. There were 43 patients, of whom 2 had a recurrence, giving a total of 45 episodes. The frequency of bezoar in our patients presenting with SBO was 4.3%. All patients were of Asian origin: 41 Chinese, 1 Indian, and 1 Malay. Twenty-eight (65%) patients had previous abdominal surgery of which 26 were gastric surgery. Thirty-eight (88%) patients were edentulous. Forty-one (91%) underwent serial abdominal radiography, whereas only 4 patients (9%) had either CT imaging or contrast study alone. Only 11 (24%) cases had a correct diagnosis of bezoar impaction made preoperatively by CT imaging. The diagnostic accuracy of CT imaging in our series was 65%, with six cases of misdiagnosis. Overall, CT led to a change in management of 76% (13 in 17). The median time to surgery from admission was 2 (0-10) days. There were 2 cases of ischemic bowel that necessitated bowel resection. The median length of hospital stay was 11 (5-100) days. Ten patients (22%) had postoperative complications, and there was one death. Bezoar-induced SBO is uncommon and remains a diagnostic and management challenge. It should be suspected in patients with an increased risk of formation of GIB, such as previous gastric surgery, poor dentition, and a suggestive history of increased fibre intake. We advocate that CT imaging be performed early in these at-risk patients and in patients presenting with SBO with or without a history of abdominal surgery in order to reduce unnecessary delays before appropriate surgical intervention.

Laparoscopic Approach Compared With Conventional Open Approach for Bezoar-Induced Small-Bowel Obstruction

Bezoar-induced small-bowel obstruction (SBO) is an uncommon surgical emergency. Accurate preoperative diagnosis is notoriously difficult, and conventional management often necessitates laparotomy. Recent articles demonstrate the feasibility of laparoscopy in the management of SBO. This study compares the outcomes of a series of cases managed laparoscopically with the outcomes of matched open cases. Laparoscopic management of bezoar-induced SBO is safe and effective when compared with traditional laparotomy treatment. A retrospective study was conducted from November 1, 1998, to November 30, 2003, to compare laparoscopic vs open treatment for bezoar-induced SBO. Patients' demographics, operative details, and surgical outcomes were evaluated. During the study period, 24 patients (16 men and 8 women) with a mean age of 68.2 years underwent operative treatments for bezoar-induced SBO. Ten patients received laparoscopic treatments and the other 14 received laparotomy treatments. The patients were comparable in age, sex, and physiological status. There were 3 conversions in the laparoscopy group owing to technical difficulties. The laparoscopic approach was associated with statistically significant shorter operative time (P = .048), fewer postoperative complications (P = .04), and reduced hospital stay (P = .009). When expertise is available, laparoscopy is safe and effective in the management of bezoar-induced SBO and is associated with superior postoperative outcomes when compared with the conventional open approach.