Meghan C. O'Bryan, Captain, USAF Medical Corps, General Surgery Resident, Department of Surgery, Wright State University, Dayton, OH; Cabot Murdock, Major, USAF Medical Corps, General and Cardiothoracic Surgeon, Wright Patterson Medical Center, Wright Patterson AFB, OH
Phytobezoar is a rare cause of alimentary tract obstruction. The authors re?port a case of ileal obstruction due to an unmasticated apricot and de?scribe the surgical treatment provided. They also review the risk factors associated with obstructing phytobezoars and discuss the various surgical treatment strategies that have been reported in the literature.
Meghan C. O'Bryan, MD
USAF Medical Corps General Surgery Resident Department of Surgery Wright State University Dayton, OH
Cabot Murdock, MD
USAF Medical Corps General and Cardiothoracic Surgeon Wright Patterson Medical Center Wright Patterson AFB, OH
More than 60% of all cases of bowel obstruction in the United States are caused by fibrous adhesions from previous surgeries, particularly within the pelvis.1 In this case, a small ileal adhesion contributed to the patient's obstruction, but the primary cause was a large apricot phytobezoar that became lodged proximal to the adhesive band. A phytobezoar is an accumulation of poorly chewed or digested food, usually fruit or vegetable matter.2
Identified risk factors for phytobezoars causing obstruction include previous gastric surgery or vagotomy (causing im?paired gastric motility), gastroparesis secondary to diabetes or spinal cord injury,3 poor mastication, and ingestion of fruits high in cellulose content, especially persimmons and oranges.2,4 A wide range of phyto?bezoars have been re?ported, including coconut fibers, cherry tomatoes, and plums. In 2002, Ihara and colleagues published the first known report of an apricot phytobezoar and its associated radiographic findings.5 This article de?scribes a similar case and the spectrum of surgical options for treating an obstructing phytobezoar.
A 59-year-old white woman with a history of hypertension and diabetes presented to the emergency department in the early morning hours because of nausea and abdominal pain, which had started 12 hours earlier. Her symptoms began shortly after dinner the evening before and continued throughout the night without relief. The patient stated that she had one loose bowel movement shortly before her arrival at the hospital and was still passing flatus. She was sent home later that morning, after receiving intravenous fluids and pain medication. The patient's surgical history included an open appendectomy, laparoscopic cholecystectomy, and vaginal hysterectomy, which made small bowel obstruction a possible diagnosis; however, this was thought to be unlikely because of the patient's recent passage of both stool and flatus.
The patient returned to the hospital 9 hours later because of worsening abdominal pain, vomiting, and an intense sensation of bloating. She had not passed any flatus since leaving the hospital earlier that day. In addition, her white blood cell (WBC) count had risen to 15.0 x 103/L with 76.6% neutrophils (increased from 12.0 x 103/L 9 hours earlier). Liver en?zymes, total bilirubin, amylase, and li?pase levels were within normal limits. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast was performed, which revealed a distinct transition point located in the mid-to-distal ileum (Figure 1). Proximal to the transition point was dilated small bowel, with an immediate decompression and narrowing of the bowel distal to this point. In 2001, Delabrousse and colleagues described similar CT findings of an obstructing phytobezoar: the transition point combined with a well-defined ovoid intraluminal mass with a mottled gas pattern is pathognomonic of this condition.6 Two years later, Zissin and colleagues echoed these findings and further described a phytobezoar obstruction as shorter and more mottled in appearance when compared with intraluminal feces-like material (small bowel feces sign) as seen on CT scanning.7
On physical examination, the patient's abdomen was soft and nondistended, and no peritoneal signs were present; however, she had diffuse discomfort to ab?dominal palpation in all four quadrants. Scant high-pitched bowel sounds were appreciated on auscultation. The only other notable finding on physical examination was the patient's partially edentulous state. Based on the radiographic findings and the patient's worsening clinical condition, the diagnosis of a complete small bowel obstruction was made and the patient was taken to the operating room for diagnostic lapar?oscopy and release of the small bowel obstruction.
?After the pa?tient was anesthetized, a camera was inserted through a 10-mm supraumbilical port. There was significant omental and intraperitoneal fat, and no clear pathology was immediately obvious. Two 5-mm lateral ports were placed, and some small adhesions were lysed from the anterior abdominal wall to allow better visualization of the structures within the right lower quadrant. Once the bowel was traced back to the site of these adhesions, there appeared to be a firm mass within the lumen of the distal ileum, the exact etiology of which was unclear. Near the site of this structure, there was also a dense adhesive band, which the bowel seemed to be wrapped around. It did not appear that the band could be safely lysed laparoscopically because the intraluminal mass seemed to be intimately involved with the site of obstruction. Based on these findings, the decision was made to perform a small laparotomy incision. The ileal segment immediately adjacent to the site of obstruction was tagged with a silk suture and the camera and ports were removed. Once the peritoneum was opened through the lapa?rotomy incision, the abdomen was explored digitally. A tight omental band was identified within the right lower quadrant. The band was brought through the incision and lysed. When the small bowel was brought up through the incision, the site of obstruction was easily identified. Just proximal to this segment, the firm structure was palpable and freely mobile within the lumen of the bowel.
The mass seemed too large to clear the ileocecal valve, thus a 3-cm longitudinal enterotomy was made with electrocautery to the segment of bowel immediately overlying the unknown object. The intraluminal mass was freely extracted and appeared to be a phytobezoar. No luminal abnormalities were identified and the enterotomy was closed. We continued to run the bowel, and a second, slightly smaller, mass was palpated proximally to the site of obstruction. This mass was milked distally past the enter-otomy closure because it appeared this piece would pass easily through the ileocecal valve and into the colon. Post?operatively, the patient recovered well and was discharged to home on postoperative day 4.
The phytobezoar was sent to pathology and later identified by the patient's history to be a whole, unchewed apricot (Figure 2). She was educated on the importance of proper preparation of food in appropriate bite-sized pieces, given her inability to fully chew her meals because of her poor dentition. Had this patient had a "virgin" abdomen free of adhesions, the phytobezoar might not have caused a complete bowel obstruction. But together, the phytobezoar and adhesive omental band led to a rapid and total small bowel obstruction, evidenced by classic radiographic signs.
A variety of surgical approaches to phytobezoar obstruction have been described in the literature. The most common technique reported has been milking a bezoar of the lumen past the ileocecal valve, where it can easily pass through the larger lumen of the colon. This has been accomplished by using open and laparoscopic approaches.8,9 To further aid in milking the bezoar into the cecum, many surgeons have fragmented the bezoar, either digitally or with laparoscopic instruments. If the intraluminal object is not positively identified preoperatively as a phytobezoar or if size or consistency prohibits more conservative surgical management, an enterotomy may be used to remove the obstructing material. On the more conservative side of the spectrum, endoscopic removal of an obstructing phytobezoar has been described.4
Within the past 5 years, less conventional yet successful methods have been reported for the surgical treatment of phytobezoars. Aslan and colleagues performed a laparotomy on a 5-year-old who had an initial diagnosis of acute appendicitis. Intraoperatively, the terminal ileum was found to be obstructed by several pieces of rubbery material. The surgeons reported concern about the enterotomy because of a severely distended cecum and an inflamed, ischemic ileum; thus they elected to evacuate the phytobezoar fragments (pieces of tangerine) via the appendiceal stump.10 Per?sim?mon phytobezoars have been fragmented using a large polypectomy snare as a "saw," a treatment that was combined with subsequent administration of cellulose, cysteine, and metoclopramide.4
Obstructing phytobezoars can lead to severe complications if left untreated, including ischemic, infarcted, or perforated bowel.2,11 The mortality rate due to phytobezoar-associated pathology is re?ported to be as high as 30%.3 Patients presenting with a clinical picture of small bowel obstruction and particularly those with the specific radiographic findings described above should be taken to the operating room for diagnostic laparo?s?copy and release of the obstruction. A higher index of suspicion for phytobezoar obstruction is required in patients with longstanding diabetes and gastroparesis, spinal cord injury, previous gastric surgery (with or without vagotomy), poor dentition (as in this case), and those with a purely vegetarian diet. One of several described surgical approaches may be performed.
Although phytobezoar is a rare cause of alimentary tract obstruction, it can be serious and even fatal. Rapid surgical intervention in the appropriate clinical setting provides relief of symptoms and prevents morbid complications.
The views expressed in this presentation are those of the presenters and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US Government.
1. Evers BM. Small intestine. In: Sabiston Textbook of Surgery. 17th ed. Philadelphia, Pa: Elsevier Saunders. 2004;1335.
2. Kim JH, Ha HK, Sohn MJ, et al. CT findings of phytobezoar associated with small bowel obstruction. Eur Radiol. 2003;13(2): 299-304.
3. Nambiar PK, Midha M, Schmitt JK. Gastric phytobezoar associated with impaired gastric motility in a patient with spinal cord injury. J Spinal Cord Med. 2002;25(1):43-45.
4. Gaya J, Barranco L, Llompart A, et al. Persimmon bezoars: a successful combined therapy. Gastrointest Endosc. 2002;55(4):581-583.
5. Ihara N, Yashiro N, Kinoshita T, et al. Small bowel obstruction due to pickled Japanese apricot: CT findings. J Comput Assist Tomogr. 2002;26(1):132-133.
6. Delabrousse E, Brunelle S, Saguet O, et al. Small bowel obstruction secondary to phytobezoar CT findings. . 2001;25(1):44-46.
7. Zissin R, Osadchy A, Gutman V, et al. CT findings in patients with small bowel obstruction due to phytobezoar. Emerg Radiol. 2004;10(4): 197-200.
8. Steinberg R, Schwarz M, Gelber E, et al. A rare case of colonic obstruction by ?cherry tomato' phytobezoar: a simple technique to avoid enterotomy. J Pediatr Surg. 2002;37(5): 794-795.
9. Yol S, Bostanci B, Akoglu M. Laparoscopic treatment of small bowel phytobezoar obstruction. J Laparoendosc Adv Surg Tech. 2003;13(5):325-326.
10. Aslan A, Unal I, Karaguzel G, et al. A case of intestinal obstruction due to phytobezoar?an alternative surgical ap?proach. Swiss Surg. 2003;9(1):35-37.
11. Fujikawa T, Matsusue S, Nishimura S, et al. "Pseudo-phytobezoar" due to seed from pickled plum resulting in perforated peritonitis. Am J Gastroenterol. 1999;94(11):3373-3374.
Although this is a report and review of a rare cause of intestinal obstruction, the recognition and treatment of a bowel obstruction in this report emphasize the importance of following fundamental principles.
Laparoscopic treatment of bowel obstruction has been very successful and reduces the length of hospitalization. No one could have guessed the cause of intestinal obstruction in this 59-year-old patient with a history of previous operations. The CT scan showed a point of small bowel obstruction and laparoscopy confirmed a firm mass in the lumen of the bowel with a dense adhesive band. The authors chose to convert to a small laparotomy incision to better evaluate and treat the underlying problem.
The laparotomy was limited because the problem area was laparoscopically localized. Recognition of the limitations of a laparoscopic approach and conversion to a limited open procedure produced an excellent result.
Performing an enterotomy and extracting an apricot phytobezoar laparoscopically would have been difficult. The principles of converting to an open operation when the diagnosis is uncertain and the laparoscopic treatment is cumbersome are hallmarks of this report. Beware of edentulous patients presenting with a small bowel obstruction! Guess phytobezoar as the cause!
Thomas Gadacz, MD
MIS Department Editor