A rare case of intestine obstruction in the edentulous

Abstract

Phytobezoar is defined as a concretion composed of vegetable matter like skins, seeds and fibres of fruit and vegetables. Phytobezoar has noted to cause small bowel obstruction, but it is a rare cause(1). It accounts for about 0.4% to 4% of all small bowel obstructions. The symptoms include vomiting, constipation, abdominal distension and pain as in any small bowel obstruction. Terminal ileum is the most common site of obstruction.(1),(2). Surgery is the main line of management in small bowel obstruction due to phytobezoar. They can be prevented by usage of prokinetics and by avoiding a high fibre diet. Here we present a 70 year old edentulous lady who came with features of intestinal obstruction. Laparotomy revealed the cause of obstruction to be plant phytobezoar

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*Corresponding author: Jayakrishna Reddy A
Sree Balaji Medical College & Hospital, Chennai -44
ISSN:0976-3031
Research Article
A RARE CASE OF INTESTINE OBSTRUCTION IN THE EDENTULOUS
Jayakrishna Reddy A., Shreya Rajkumar., Senthil Kumar S., Darwin P and Rajkumar J.S
Sree Balaji Medical College & Hospital, Chennai -44
DOI: http://dx.doi.org/10.24327/ijrsr.2017.0810.0902
ARTICLE INFO ABSTRACT
Phytobezoar is defined as a concretion composed of vegetable matter like skins, seeds and fibres of
fruit and vegetables. Phytobezoar has noted to cause small bowel obstruction, but it is a rare
cause(1). It accounts for about 0.4% to 4% of all small bowel obstructions. The symptoms include
vomiting, constipation, abdominal distension and pain as in any small bowel obstruction. Terminal
ileum is the most common site of obstruction.(1),(2). Surgery is the main line of management in
small bowel obstruction due to phytobezoar. They can be prevented by usage of prokinetics and by
avoiding a high fibre diet. Here we present a 70 year old edentulous lady who came with features of
intestinal obstruction. Laparotomy revealed the cause of obstruction to be plant phytobezoar.
INTRODUCTION
Phytobezoar is a concretion composed of vegetable matter like
skins, seeds and fibres of fruit and vegetables.
Bezoars are normally found in the stomach, they may pass into
the small bowel. Phytobezoar can also develop secondary to
Crohn’s disease,tumor, tuberculosis or previous surgery with
stricture or small bowel diverticular disease ,poor mastication
and edentulous jaws, rapid swallowing of large amounts fruits
and vegetables.(3),(2),(4) In such cases, the bile constituents or
calcium salts contribute to bezoar development.
Case report
Here we present an interesting case of a 70 year old female
who came with features of intestinal obstruction.
She presented with complaints of colicky abdominal pain
associated with bilious vomiting for 2 days and was obstipated
for 4 days. She had similar complaints 3 months ago. Previous
CECT abdomen showed mild distension of ileum and multiple
mesenteric lymph nodes at the distal ileum and ileocecal
junction.She underwent an inconclusive diagnostic laparoscopy
and node biopsy. Histopathology of node biopsy was
suggestive of nonspecific inflammation
She is a known case of type 2 diabetes mellitus, hypertension,
and hypothyroidism on regular treatment. On examination, she
was hemodynamically stable. However, her abdomen was
distended without any visible peristalsis and nil signs of
peritonitis. Bowel sounds were hyperactive. Rectal examination
was normal. CECT abdomen (figure 1) showed small bowel
obstruction involving the ileal loop showing small bowel faeces
sign with abrupt zone of transition at the junction of mid and
distal ileal loops. Minimal free fluid was found in the
pelvisthere was no evidence of gall stones.
Axial view(a, b) of computed tomography (CT) of the abdomen
showing grossly dilated, thick-walled small bowel loops up to
the region of the pelvis.
Coronal view(c) of the computed tomography (CT) of the
abdomen showing grossly dilated thickened small bowel loops
up to the region of right iliac fossa.
She was taken up for diagnostic laparoscopy(5) and was found
to have multiple mesenteric nodes, multiple dilated bowel
loops with collapsed distal ileum, impacted food bolus (bezoar)
noted in ileum around 120-150 cm from ileocecal junction,
with moderate ascites. Impacted bezoar was not able to be
milked towards the caecum. Following which a transverse
incision was made at the level of umbilicus, thorough bowel
walk was done, and the site of impacted bezoar was identified.
The site of obstruction was opened longitudinally and
decompression of the entire small bowel along with the bezoar
done. Strictured small bowel resected (15-20 cm) and end to
end anastomosis done, mesenteric nodes biopsy taken.
Available Online at http://www.recentscientific.com
International Journal of
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Research
International Journal of Recent Scientific Research
Vol. 8, Issue, 10, pp. 20490-20492, October, 2017
Copyright © Jayakrishna Reddy A et al, 2017, this is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the
original work is properly cited.
DOI: 10.24327/IJRSR
CODEN: IJRSFP (USA)
Article History:
Received 16th July, 2017
Received in revised form 25th
August, 2017
Accepted 23rd September, 2017
Published online 28th October, 2017

Jayakrishna Reddy A
Histopathology reports suggested
of vegetable matter with
distal hypertrophic constriction ring in the bowel wall. Lymph
node showed non-specific inflammation.
DISCUSSION
The word 'bezoar' is derived from the Persian word 'padzahr'
which means counter-poison or antidote(4)
. This word was first
applied to a greenish, hard concretion found in the fourth
stomach of the Syrian goat. The stone was felt to prevent
poisoning and came
to Europe as the bezoar
highly prized for its medicinal properties.
There are 4 types of bezoars. Phytobezoars are the most
common, and are composed of vegetable matter and it contains
large amount of non-
digestable fibres. Trichobezoar
gastric concretion of hair fibres which usually presents in
psychiatric patients. Pharmacobezoars consist of medication
bezoars. Lactobezoars are milk curd secondary to infant
formula usually seen in low birth weight neonates.
Small bowel obstruction accounts for 20% of hospital
admission. Common causes are adhesions, strangulated hernia,
malignancy, volvulus
, gallstones, foreign bodies
bowel disease, hypothyroidism and diabeticgastro paresis
(2),(1),(6)
. Phytobezoars are rare, accounting for only 0.4
of all intestinal obstruction. N
o particular age has been
observed, but this is slighting more common in males.
Jayakrishna Reddy A
et al., A Rare Case of
Intestine Obstruction In An Edentulous
of vegetable matter with
distal hypertrophic constriction ring in the bowel wall. Lymph
The word 'bezoar' is derived from the Persian word 'padzahr'
. This word was first
applied to a greenish, hard concretion found in the fourth
stomach of the Syrian goat. The stone was felt to prevent
to Europe as the bezoar
-stone which was
There are 4 types of bezoars. Phytobezoars are the most
common, and are composed of vegetable matter and it contains
digestable fibres. Trichobezoar
s are
gastric concretion of hair fibres which usually presents in
psychiatric patients. Pharmacobezoars consist of medication
bezoars. Lactobezoars are milk curd secondary to infant
formula usually seen in low birth weight neonates.
(1)
Small bowel obstruction accounts for 20% of hospital
admission. Common causes are adhesions, strangulated hernia,
, gallstones, foreign bodies
, inflammatory
bowel disease, hypothyroidism and diabeticgastro paresis
. Phytobezoars are rare, accounting for only 0.4
-4%
o particular age has been
observed, but this is slighting more common in males.
Primary small bowel bezoars are very rare and invariably
causes obstruction of small
phytobezoar induced sm
all bowel obstruction is similar to
obstruction due to othe
r causes, such as pain abdomen
distension of abdomen, na
usea, vomiting and constipation
Hence,
it is difficult to differentiate between small
obstruction due to phytobezoar and adhesions
patients who have previous history of abdominal
surgery.(7),(1),(4)
Our working diagnosis was intestinal
obstruction due to faecal matter or vegetable matter impaction.
Plain supine x-
ray shows a classic obstructive pattern of small
bowel occasionally outline of bezoar can be made out, which
difficult to differentiate between abscess and faeces within the
ileum.
The diagnostic rate of abdominal ultrasound in detecting
phytobezoar is reported to be 88%
dependent and bezoar can be concealed by bowel gas.
patie
nt both investigations showed features suggestive of small
bowel obstruction.
The cause of obstruction can be diagnosed
by computed tomography in 73%
diagnostic accuracy for bezoar induced small bowel obstruction
is about 65%-100%.(8),(1)
investigation that confirms the level
multiple bezoars as well as any complications such as bowel
ischemia and perforation.
Well defined intra
mottled gas appearance associated with encapsulated wall is
suggestive of phytobezoar.
Figure 1 CECT Abdomen
Intestine Obstruction In An Edentulous
20491 | P a g e
Primary small bowel bezoars are very rare and invariably
causes obstruction of small
bowel. Clinical presentation of
all bowel obstruction is similar to
r causes, such as pain abdomen
,
usea, vomiting and constipation
.
it is difficult to differentiate between small
bowel
obstruction due to phytobezoar and adhesions
, particularly in
patients who have previous history of abdominal
Our working diagnosis was intestinal
obstruction due to faecal matter or vegetable matter impaction.
ray shows a classic obstructive pattern of small
bowel occasionally outline of bezoar can be made out, which
is
difficult to differentiate between abscess and faeces within the
The diagnostic rate of abdominal ultrasound in detecting
phytobezoar is reported to be 88%
-93%.But it is operated
dependent and bezoar can be concealed by bowel gas.
In this
nt both investigations showed features suggestive of small
The cause of obstruction can be diagnosed
by computed tomography in 73%
-95% of patients and its
diagnostic accuracy for bezoar induced small bowel obstruction
It is an operator dependent
investigation that confirms the level
of obstruction, existence of
multiple bezoars as well as any complications such as bowel
Well defined intra
-luminal mass with
mottled gas appearance associated with encapsulated wall is

International Journal of Recent Scientific Research Vol. 8, Issue, 10, pp. 20490-20492, October, 2017
20492 | P a g e
The treatment of choice of small bowel obstruction due to
phytobezoar is surgery. Most bezoars in small bowel are found
50cm-70cm proximal to ileocecal valve because it is narrow,
slow intestinal motility and large amount of water absorption
hardens the bezoar resulting in losing its motility.(1),(9)
Surgical options reported are manual fragmentation of
phytobezoar and pushing it towards caecum. If it is not possible
enterotomy should be done to remove the bezoar.(9) Segmental
bowel resection and anastomosis may be required in presence
of complications such as gangrene of bowel and stricture. At
the time of laparotomy thorough exploration of the abdominal
cavity should be done to exclude the presence of concomitant
gastric bezoar or intestinal bezoars.(2)About 1/3rd of the
patients have multiple intestinal bezoars. Laparoscopic
management of phytobezoar induced small bowel obstruction
have been reported however it requires expertise.(5)In most
cases, surgical treatment of small bowel obstruction can be
accomplished successfully. General preventive measures
include avoidance of high fibre diet, more water consumption,
proper mastication, and treatment of underlying gastrointestinal
motility disorders.(7),(4)
CONCLUSION
Small bowel phytobezoar is an uncommon cause of acute
intestinal obstruction in the elderly with a virgin abdomen.
Preoperative aetiologic diagnosis based on history and physical
examination may be difficult. It is common in old and
edentulous people with large amount fruits and vegetables in
diet.(7)Plain abdominal X-ray and ultrasound findings are that
of nonspecific small bowel obstruction. Abdominal CT scan is
helpful in excluding other differential diagnoses.(8) Surgery is
often required in resolving the diagnostic puzzle and for
definitive treatment. Recurrence following treatment is
common and can be prevented by appropriate dietary habits
and control of underlying factors.(1)
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15793871
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How to cite this article:
Jayakrishna Reddy A et al.2017, A Rare Case of Intestine Obstruction In An Edentulous. Int J Recent Sci Res. 8(10), pp. 20490-
20492. DOI: http://dx.doi.org/10.24327/ijrsr.2017.0810.0902