Small bowel obstruction produced by a phytobezoar

Aims: Bezoars are conglomerates that may consist of undigested vegetable fibers (phyto-bezoar) or hairs (tricho-bezoar). Phytobezoars are a rare cause of gastrointestinal obstruction, occurring mainly in patients with previous acid- reducing gastric surgery.

Case report: A 68-year-old Caucasian man was admitted to the hospital with a history of daily vomiting and weight loss of 8kg within three weeks. The patient had undergone a selective proximal vagotomy with pyloroplasty for a bleeding duodenal ulcer (1981) and a Billroth reconstruction with distal gastrectomy for a perforated NSAID induced gastric ulcer(1999). At the physical exam the patient presented the postoperative abdominal scar and a slight pain in the left upper abdominal quadrant with normal bowel sounds. Laboratory data revealed a modest increase of the C-reactive protein to 7mg/l(range <5). Upper gastrointestinal endoscopy demonstrated a dilated residual stomach filled with fluid and a normal gastroduodenal anastomosis. Abdominal MRI performed as enteroclysma (MR-Sellink) showed fluid-filled and dilated small intestinal bowel (proximal jejunum) with an intraluminal mass, demonstrating decreased signal on T2- and T1-weighted images and no contrast-enhancement after intravenous contrast material administration. The patient underwent an explorative laparotomy. The laparotomy revealed adhesions between jejunum and the anterior abdominal wall and an intraluminal phytobezoar at 90cm after the ligament of Treitz. Because the affected jejunum loop was fixed through adhesions to the abdominal wall nether “milking“ nor enterotomy was possible, so that a resection of 20cm jejunum was performed.

Conclusion: Phytobezoars should be considered in the differential diagnosis of patients presenting with mechanical small bowel obstruction, especially in those with previous ulcer surgery.Small bowel obstruction secondary to phytobezoars should be distinguished from similar conditions secondary to adhesions. Surgery is required in the treatment of intestinal bezoars. The method of choice for intestinal bezoars is fragmentation and milking to the cecum, reserving enterotomy or resection for cases where this is not possible.

Key Words: Phytobezoar- Small bowel obstruction- Previous ulcer surgery