Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

ABDOMINAL IMAGING
Year
: 2016  |  Volume : 26  |  Issue : 4  |  Page : 443--445

An unusual sigmoid phytobezoar in a patient with a transplanted kidney: A case report


Paola Milillo, Angelo Pio Moffa, Vincenzo Bertozzi, Roberta Vinci, Luca Macarini 
 Department of Radiology, University of Foggia, Foggia, Italy

Correspondence Address:
Paola Milillo
Department of Radiology, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia
Italy

Abstract

Bezoars are masses formed by the concretion of stomach contents or debris within the gastrointestinal tract. Bezoars are rare and account for only 0.4–4% of all cases of gastrointestinal obstruction and mainly occur in the stomach or small intestine. Intestinal obstruction caused by colonic bezoars is extremely rare. A 39-year-old man with a transplanted kidney came to the hospital because of abdominal pain, constipation, and distension. We performed an abdominal computed tomography scan and found an ovoid intraluminal mass with a mottled gas pattern in the distal sigmoid colon. Subsequently, the patient underwent laparotomic surgery and removal of the bezoar. We report a rare case of large bowel obstruction due to colonic phytobezoar, which was confirmed intraoperatively.



How to cite this article:
Milillo P, Moffa AP, Bertozzi V, Vinci R, Macarini L. An unusual sigmoid phytobezoar in a patient with a transplanted kidney: A case report.Indian J Radiol Imaging 2016;26:443-445


How to cite this URL:
Milillo P, Moffa AP, Bertozzi V, Vinci R, Macarini L. An unusual sigmoid phytobezoar in a patient with a transplanted kidney: A case report. Indian J Radiol Imaging [serial online] 2016 [cited 2017 Feb 21 ];26:443-445
Available from: http://www.ijri.org/text.asp?2016/26/4/443/195772


Full Text

 Introduction



Bezoars are masses formed by the condensation of debris or stomach contents in the gastrointestinal tract. There are four major types of bezoars: A trichobezoar consists of hair, a phytobezoar of vegetable and fruit residues, a lactobezoar is formed from dairy products, a pharmacobezoar is caused by medications.[1]

A high-fiber diet, incomplete mastication, reduced gastric secretion, and decreased gastrointestinal motility from autonomic neuropathy can predispose patients to phytobezoar formation. It occurs more frequently in the small intestine, particularly in the terminal ileum and jejunum. The occurrence of colonic obstructions caused by bezoars is considered pretty rare.[2],[3]

The complications caused by bezoars are mechanical irritation, gastrointestinal obstruction, and, in severe cases, peritonitis caused by bowel perforation.[4]

Bezoars are responsible for 0.4–4% of cases of mechanical intestinal obstruction, which occurs mainly in the stomach and small intestine.[2] Contrast-enhanced computed tomography (CT) is the method of choice to identify the location, severity, and etiology of intestinal obstruction.[5]

We describe our experience regarding a large-bowel obstruction caused by phytobezoar in a patient with a transplanted kidney.

 Case Report



A 39-year-old man was admitted to our hospital for constipation, distension, and severe acute abdominal pain in the lower left quadrant. His medical history included Alport syndrome resulting in progressive chronic kidney disease (CKD), hypertension, and iron deficiency anemia under medical treatment. Twelve years ago, he received a successful deceased-donor kidney transplant [Figure 1]. At the time of admission, vitals were stable, and he was afebrile. Abdominal examination revealed distention with no signs of peritonitis. Laboratory data were unremarkable. Chest X-ray was normal and abdominal X-ray did not show signs of bowel obstruction. Overnight, the patient experienced an increased pain on left side of the abdomen.{Figure 1}

Non-contrast CT (NCCT) of the abdomen was done (Toshiba ® Aquilion 64-TSX-101A/HC) as the patient had CKD (serum creatinine level = 7.71 mg/dL). CT scan revealed a focal circumferential thickening of the sigmoid colon with an ovoid and encapsulated intraluminal mass measuring 4.7 × 3.6 cm [Figure 2]. The mass had a mean attenuation value of 10.21 HU. Dilatation of the proximal segment with abundant fecal material was seen [Figure 2]. Based on the CT findings, particularly mottled gas pattern and encapsulated wall of the mass, we made the diagnosis of phytobezoar. Hence, because of acute intestinal obstruction and to avoid peritonitis, the patient underwent urgent exploratory laparotomy.{Figure 2}

The obstructive intraluminal mass in the sigmoid colon was identified (approximately 4 × 4 cm in size) and manually broken down with evacuation of the obstructive material along with large amounts of liquid fecal material. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day. At 3-month follow-up, the patient was free of gastrointestinal symptoms.

 Discussion



Phytobezoars are concretions of poorly digested fruit and vegetable fibres that are found in the alimentary track and are mostly composed of indigestible cellulose, tannin, and lignin from ingested vegetables and fruits. The most common phytobezoars encountered worldwide are related to the ingestion of persimmon fruit. Normally, they are found in the stomach and may enter into the small bowel. The most important risk factors for phytobezoar formation are excessive consumption of fruits rich in fibers, poor dental health, insufficient mastication, diabetic gastroparesis, kidney failure, hypothyroidism, use of drugs which affect gastric motility,[6] and previous gastrointestinal surgery.[7]

In our case, previous history of abdominal surgery was confirmed as a predisposing factor for phytobezoar. Clinically, patients with colonic bezoars most commonly present with abdominal pain. Other symptoms include abdominal distension, vomiting, constipation, diarrhoea, anorexia, and weight loss. If treatment is delayed, colonic bezoars can be complicated by intestinal obstruction and perforation with consequent peritonitis.[7]

Plain abdominal radiography and CT scan are used for radiological evaluation of the patients presenting with intestinal obstruction. Simple abdominal X-ray may reveal air-fluid levels associated with mechanical obstruction,[5] and occasionally it is possible to see the outline of bezoar, which is difficult to differentiate from abscess or feces within the colon.[8]

On abdominal CT, 89% of bezoars appear as spherically-shaped masses containing air-fluid levels.[1] CT is also helpful in discriminating bezoars from other causes of bowel obstruction such as gastrointestinal malignancies, gallstone ileus, etc.[1],[9]

In our case the differential diagnosis, especially with fecal impaction, was very difficult. Indeed, many authors have highlighted some CT features to allow easier differential diagnosis between these two entities. Small bowel feces tends to be more amorphous and tubular in shape without evidence of an encapsulating wall,[4],[10] whereas phytobezoars have a well-defined ovoid shape and an encapsulating wall, such as in our case.[11] Chen et al.[12] showed that a higher grade of obstruction is commonly associated with phytobezoar impaction without mesenteric fatty stranding and intraperitoneal fluid; moreover, they found that a combination of the food debris length <9.5 cm and the mean attenuation value <11.75 HU of the obstructed bowel at the transition point was suggestive for phytobezoar, such as in our patient. Although these features are typically found in the small bowel, they may also be considered very useful in the large bowel.

There are several treatment options for colonic bezoars. In general, treatment differs according to the location and size of bezoar and presence of complications.[1]

Conservative management is considered in uncomplicated cases of colonic bezoars and consist of digital evacuation, enemas and manual disimpaction.[7]

If conservative approach fails, a colonoscopy can be attempted for bezoar removal [1] with contextual mechanical fragmentation and extraction using several instruments. Although endoscopy has an acceptable success rate and fewer complications than surgery, surgical approach is mandatory in case of endoscopic treatment failure, sigmoid volvulus, hematochezia, intestinal obstructions, perforations, or peritonitis.[13],[14]

When surgical approach is chosen, the first step is intestinal decompression and fluid-electrolyte replacement; later, open or laparoscopic abdominal exploration may be performed.[5]

In our case, the patient underwent laparotomic surgery and phytobezoar was manually broken down with evacuation.

 Conclusions



Bezoar is a rare disorder, however, it must be suspected in case of mechanical intestinal obstruction. Our case underlined the importance of early detection and removal of a bezoar to prevent complications such as obstruction, perforation, or peritonitis. CT scan is essential for the diagnosis and an accurate preoperative assessment. Surgical approach is indicated for bezoars causing intestinal obstruction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Yoon SS, Kim MS, Kang DY, Yun TS, Jeon JH, Lee YK, et al. A Case of Successful Colonoscopic Treatment of Colonic Obstruction Caused by Phytobezoar. J Korean Soc Coloproctol 2011;27:211-4.
2Bala M, Appelbaum L, Almogy G. Unexpected cause of large bowel obstruction: Colonic bezoar. Isr Med Assoc J 2008;10:829-30.
3Ramos J, Dean DE, Tarakji E, Rich J. Impacted foreign body in the sigmoid colon presenting as recurrent diverticulitis. Clin J Gastroenterol 2011;4:104-7.
4Kim JP, Park JG, Hong SC, Lee KU, Park JW, Kwon OJ, et al. Clinical analysis of Bezoars. Korean J Gastroenterol 1991;23:32-8.
5Dikicier E, Altintoprak F, Ozkan OV, Yagmurkaya O, Uzunoglu MY. Intestinal obstruction due to phytobezoars: An update. World J Clin Cases 2015;3:721-6.
6Pujar KA, Pai AS, Hiremath VB. Phytobezoar: A rare cause of small bowel obstruction. J ClinDiagn Res 2013;7:2298-9.
7Law GW, Lin D, Thomas R. Colonic phytobezoar as a rare cause of large bowel obstruction. BMJ Case Rep 2015;9;2015.
8Teng H, Nawawi O, Ng K, Yik Y. Phytobezoar: An unusual cause of intestinal obstruction. Biomed Imaging Interv J 2005;1:e4.
9Angelelli G, Magliocca M, Zaccheo N, Vinci R, Rotondo A. Intestinal obstruction caused by phytobezoar: Computerized tomography findings. Report of 3 cases. Radiol Med 1997;93:789-91.
10Oktar SO, Erbaş G, Yücel C, Aslan E, Ozdemir H. Closed perforation of the small bowel secondary to a phytobezoar: Imaging findings. Diagn Interv Radiol 2007;13:19-22.
11Delabrousse E, Lubrano J, Sailley N, Aubry S, Mantion GA, Kastler BA. Small-bowel bezoar versus small-bowel feces: CT evaluation. AJR Am J Roentgenol2008;191:1465-8.
12Chen YC, Liu CH, Hsu HH, Yu CY, Wang HH, Fan HL, et al. Imaging differentiation of phytobezoar and small-bowel faeces: CT characteristics with quantitative analysis in patients with small- bowel obstruction. Eur Radiol 2015;25:922-31.
13Park SE, Ahn JY, Jung HY, Na S, Park SJ, Lim H et al. Clinical outcomes associated with treatment modalities for gastrointestinal bezoars. Gut Liver 2014;8:400-7.
14Karpagam B, Vinayagam S, Kishore J, Samuel J. Isolated Adult Hypoganglionosis Presenting as Sigmoid Phytobezoar: A Case Report. Int J Sci Stud 2015;2:139-41.