Small Bowel Bezoars Research Articles

Colonic phytobezoar in a child

AbstractGastric bezoars and small bowel bezoars are uncommon in the pediatric population, and colonic bezoars are even rarer. We present the case of a 9‐year‐old female who presented with acute abdominal obstruction symptoms and a diagnosis of colonic phytobezoar. The phytobezoar was removed via endoscopic intervention. This case is important as it demonstrates that colonic bezoars can occur in children, may not be amenable to oral laxative or enema therapy, and may require endoscopic removal.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

Ultrasonography evaluation of small bowel bezoars with suspicious findings on CT in the elderly

Aim: Our aim was to evaluate the feasibility of using ultrasonography (US) in the detection and management of small bowel bezoars in elderly patients (> 65 y).Material and Methods: This study included 15 elderly patients (> 65 y) with small bowel obstruction and initial diagnosis of small bowel bezoar using abdominal computed tomography (CT) from among 182 patients with small bowel obstruction. The diagnostic performance of US was prospectively evaluated and compared with the surgical or clinical diagnoses.Results: Among the 15 patients, ten of them were diagnosed via ultrasonography as having small bowel bezoar. Eight patients were also surgically diagnosed with phytobezoars, and the remaining two patients who showed bezoars on US showed complete symptomatic improvement with ultrasonographic follow-up showing the bezoar passing through the cecum. The other five patients were surgically diagnosed with brid ileus. US correctly diagnosed small bowel bezoars in all patients. The sonographic follow-up of the bezoars in the two patients who showed symptomatic improvement was also successful.Conclusion: US is a feasible imaging modality for the diagnosis and follow-up of small bowel bezoars. Timely diagnosis and management of bezoars is especially important in elderly patients. US can help both, radiologists and clinicians in easy diagnosis and timely management of small bowel bezoars in elderly patients.Keywords: Bezoar; phytobezoar; ultrasonography; computed tomography; elderly.

Bezoars: a rare cause of rapunzel syndrome and large bowel obstruction by sigmoid volvolus

Background: Bezoars are conglomerates of indigested materials that accumulate in the gastrointestinal tract. The aim of this work was to study our cases of bezoars and its different management modalities. Methods: This is a retrospective study of the patients diagnosed to have gastrointestinal bezoars that were admitted to our institute from the start of 2008 to the end of 2014. The clinical data, management, and outcomes of these patients were studied. Results: Bezoars were present in 8 patients. There were 5 female patients (62.5%) and 3 males, and the median age was 28 years (range: 16-54). Gastric bezoars were present in 5 patients, all were females and all were trichobezoars. One of them was extending to the duodenum with a tail of hair, making what is called rapunzel syndrome. Two were treated by endoscopy, two needed open laparotomy with gastrotomy and one treated conservatively. Small bowel bezoars were phytobezoars that caused small bowel obstruction in two male patients. One treated conservatively, and laparotomy and enterotomy done in another patient. One male patient with sigmoid bezoars caused volvolus and ischemia of the sigmoid colon. This was treated with laparotomy, sigmoid resection and colostomy. There were no mortality and very low morbidity. Conclusions: Bezoars are uncommon causes of gastrointestinal diseases. Presentations depend on the site and size of the bezoars. Gastric bezoars are usually trichobezoars and are more common in young females. Rapunzel syndrome is a rare presentation of trichobezoars. Small bowel bezoars are usually phytobezoars, and their usual presentation is small bowel obstruction. Sigmoid volvolus is a very rare presentation of colonic bezoars. Different treatment modalities are needed according to its type and location.

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.

Color Doppler Twinkling Artifacts in Small-Bowel Bezoars

Small-bowel bezoars usually form in the stomach and may subsequently cause small-bowel obstruction. Bezoars associated with small-bowel obstruction have been accurately diagnosed by computed tomography, although some case reports have described the specific sonographic findings of small-bowel bezoars. Bezoars can be overlooked by sonographic examination if a dilated small-bowel loop contains a large amount of air. Twinkling artifacts on color Doppler images appear as rapidly fluctuating red and blue signals behind certain strongly reflecting structures. In this series, we hypothesize that twinkling artifacts might appear in small-bowel bezoars, and we describe the presence of twinkling artifacts in 3 cases of small-bowel bezoars presenting as small-bowel obstruction.

A Case of Small Bowel Obstruction Caused by Bezoars Diagnosed with Double Balloon Enteroscopy

Primary small bowel bezoars are rare and cause acute abdomen due to small bowel obstruction (SBO). A 69-year-old Japanese man presented with epigastric pain associated with fullness. Physical examination of the abdomen showed no marked signs of peritoneal irritation. An erect X-ray film of the abdomen showed small bowel obstruction. Computed tomography (CT) showed a dilated small bowel loop proximal to the site of the obstruction. Retrograde double balloon enteroscopy (DBE) was performed and showed yellow, hard bezoars blocking the distal ileum. At surgery, a bezoar was found impacted in the distal ileum, and enterotomy with extraction was performed. After 9 days, the patient was discharged from our hospital in satisfactory condition. DBE also appears to be a safe and useful diagnostic tool in patients with SBO, and the findings of DBE influence the strategy of therapy in patients in whom the cause of SBO could not be determined by conventional radiography.

Endoscopic Removal of Efferent Loop Bezoars in Postgastretomy Pateints

Efferent loop bezoars rarely occur. However when patients have a history of gastrectomy and gastrojejunal anastomosis, they are sometimes found. Small bowel obstruction by efferent loop bezoar has a mortality rate as high as 30%. Although various endoscopic procedures were reported to remove gastric bezoars, the traditional treatment option of small bowel bezoars is operative management. But as in the cases we describe here, endoscopic procedure may offer an effective alternative for efferent loop bezoars. Bezoars obstructing efferent loop were found in patients with history of gastrectomy and they were removed by endoscopy successfully. (Korean J Helicobacter Up Gastrointest Res 2012;12:124-127)

Phytobezoar in a jejunal diverticulum as a cause of small bowel obstruction: a case report

IntroductionPhytobezoars are concretions of poorly digested fruit and vegetable fibers found in the alimentary tract. Previous gastric resection, gastrojejunostomy, or pyloroplasty predispose people to bezoar formation. Small-bowel bezoars normally come from the stomach, and primary small-bowel bezoars are very rare. They are seen only in patients with underlying small-bowel diseases such as diverticula, strictures, or tumors. Primary small-bowel bezoars almost always present as intestinal obstructions, although it is a very rare cause, being responsible for less than 3% of all small-bowel obstructions in one series. Jejunal diverticula are rare, with an incidence of less than 0.5%. They are usually asymptomatic pseudodiverticula of pulsion type, and complications are reported in 10% to 30% of patients. A phytobezoar in a jejunal diverticulum is an extremely rare presentation.Case presentationA 78-year-old Pakistani man presented to our clinic with small-bowel obstruction. Upon exploration, we found a primary small-bowel bezoar originating in a jejunal diverticulum and causing jejunal obstruction. Resection and anastomosis of the jejunal segment harboring the diverticulum was performed, and our patient had an uneventful recovery.ConclusionPrimary small-bowel bezoars are very rare but must be kept in mind as a possible cause of small-bowel obstruction.

Small-Bowel Bezoar Versus Small-Bowel Feces: CT Evaluation

The objective of our study was to evaluate the accuracy of CT for differentiating small-bowel bezoar from small-bowel feces in cases of small-bowel obstruction (SBO). In cases of SBO, although some CT features of bezoars and small-bowel feces overlap, a well-defined mass mottled with gas bubbles associated with an encapsulating wall, the newly described "floating fat-density debris" sign, and a lesion in the stomach that appears similar to the obstructing mass is typical of a small-bowel bezoar; an isolated amorphous mass mottled with gas bubbles is typical of small-bowel feces.

Obstructing Small Bowel Bezoars Due to an Agar Diet: Diagnosis Using Double Balloon Enteroscopy

Primary small bowel bezoars are rare and may cause acute abdomen due to small bowel obstruction (SBO). A 70-year-old Japanese woman presented to the emergency room with abdominal pain, nausea and vomiting. The patient reported that she had eaten a large amount of highly-concentrated, agar dissolved in boiling water two days prior to presentation. Double balloon enteroscopy (DBE) revealed that white-colored, hard bezoars were clogged in the jejunum. At surgery, many bezoars were found impacted in the distal jejunum, and enterotomy was performed. The bezoars were elastic hard, crystallized objects. These bezoars were considered to have formed from highly-concentrated, dissolvable agar.

Laparoscopy-Assisted Management of Jejunal Bezoar Obstruction

Treatment of intestinal bezoar causing obstruction is usually straightforward by an open approach, with either digital fragmentation or removal of the bezoar via an enterotomy. Herein, we report a case of small bowel bezoar obstruction treated successfully by laparoscopic technique. The bezoar was fragmented manually via a minilaparotomy and then pushed into the cecum with laparoscopic forceps. Laparoscopic management is an alternative to conventional surgery for intestinal bezoar that provides shorter hospital stay and less postoperative pain and may be recommended as the treatment of choice of such patients.

Phytobezoar: an unusual cause of intestinal obstruction

Small bowel phytobezoars are rare and almost always obstructive. There have been previously reported cases of phytobezoars in the literature, however there are few reports on radiological findings for small bowel bezoars. Barium studies characteristically show an intraluminal filling defect of variable size that is not fixed to the bowel wall with barium filling the interstices giving a mottled appearance. On CT scan, the presence of a round or ovoid intraluminal mass with a ‘mottled gas’ pattern is believed to be pathognomonic. Since features on CT scans are characteristics and physical findings are of little assistance in the diagnosis of bezoar, the diagnostic value of CT needs to be emphasised.

Gastrointestinal bezoars: A retrospective analysis of 34 cases

Bezoars (BZ) are the most common foreign bodies of gastrointestinal tract. Clinical manifestations vary depending on the location of BZ from no symptoms to acute abdominal syndrome. When located in small bowel, they frequently cause small bowel obstruction (SBO). We aimed to present our experience by reviewing literature. Thirty-four patients with gastrointestinal BZ were presented. The data were collected from hospital records and analyzed retrospectively. Morbidity and mortality rates were statistically analyzed between the subgroups according to SBO and endoscopic or surgical treatment modalities. The 34 patients had phytobezoars (PBZ). Two patients with mental retardation and trichotillomania had trichobezoars (TBZ). More than half of them (55.88%) had previous gastric surgery. Also most of them had small bowel bezoars resulting in obstruction. Surgical and endoscopic morbidity rates were 32.14% and 14.28% respectively. The total morbidity rate of this study was 29.41%. Four patients in surgically treated group died. There was no death in endoscopically treated group. The total and surgical mortality rates were 11.76% and 14.28% respectively. The differences in morbidity and mortality rates between the subgroups were not statistically significant. BZ are commonly seen in stomach and small intestine. SBO is the most common complication. When uncomplicated, endoscopic or surgical removal can be applied easily.