|
|
CASE REPORT |
|
Year : 2013 | Volume
: 3
| Issue : 1 | Page : 59-62 |
|
An unusual cause of intestinal obstruction: Plastobezoar
Pankaj K Garg, Divya Sharda, Ashwani Kumar, Vijay K Sharda
Department of Surgery, Government Medical College, Rajindra Hospital, Patiala, Punjab, India
Date of Web Publication | 28-Aug-2013 |
Correspondence Address: Pankaj K Garg Department of Surgery, Government Medical College/Rajindra Hospital, Patiala - 147 001, Punjab India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/2278-9596.117130
Bezoars are usually present as a mass in the stomach. It is formed due to eating non-food items like hair (trichobezoar), vegetable matter (phytobezoar), and sand bezoar. There are many such cases reported in literature of bezoars but there very few cases of bezoar formed by plastic material. We report an unusual case of plastobezoar that was extending from the stomach to distal ileum, and the patient presented with features of intestinal obstruction. An 8-year-old female child was admitted with history of abdominal pain and constipation for 3 days. Her mother gave a history of ingestion of plastic fibers from mattress filled with plastic fibers by the patient. Abdominal examination revealed moderate distention and tenderness but with no features of peritonitis. Mental health assessment was performed by the psychiatrist and it did not reveal any gross abnormality. Following clinical examination, laboratory test and radiological imaging background, a diagnosis of intestinal obstruction due to bezoar was made. After proper resuscitation, laparotomy was performed and plastobezoar was removed from stomach and intestine through a gastrostomy and enterostomy respectively. Both stomach and intestine were primarily closed. Other abdominal viscera were normal. Abdominal cavity was closed in layers. Post operative period was uneventful. Patient was discharged in satisfactory condition. Early diagnosis of bezoar should be made by detailed history and psychiatric evaluation so that they can be treated endoscopically to avoid laparotomy and operative mortality. Keywords: Intestinal obstruction, plastophagia, plastobezoar, stomach
How to cite this article: Garg PK, Sharda D, Kumar A, Sharda VK. An unusual cause of intestinal obstruction: Plastobezoar. Arch Int Surg 2013;3:59-62 |
Introduction | | |
Bezoars are rare and are often reported in patients with some psychiatric ailment. [1],[2],[3] They usually present with signs and symptoms due to a mass in the stomach and may rarely extend in to the jejunum as a tail (Rapunzel syndrome). [3],[4],[5] Sometimes the tail dislodges from stomach and presents as intestinal bezoar causing intestinal obstruction. Isolated presentation in the ileum without a parent bezoar in the stomach is rare. Stomach bezoars, if detected in time, may be treated by endoscopic retrieval, but if presentation is in the form of intestinal obstruction with or without perforation, management is by a formal exploratory laparotomy. [5],[6],[7],[8] The objective of this paper is to present the successful management of a unique case of plastobezoar, which extended from the stomach to the ileum.
Case Report | | |
An 8-year-old female child was admitted with history of colicky abdominal pain, distention, and constipation for 3 days. Her mother gave a history of ingestion of plastic fibers from mattress filled with plastic fibers by the patient. Abdominal examination revealed moderate distention and tenderness but with no features of peritonitis. Mental health assessment was performed by the psychiatrist and it did not reveal any abnormality. Laboratory tests of patient were in normal range (Hemoglobin (Hb) 10.4 mg/dl, Total Leukocyte Count (TLC) 8439, Blood Urea 28 mg/dl, Serum Creatinine 0.6 mg/dl, Random Blood Sugar 124 mg/dl, Serum Sodium 135 meq/dl, and Serum Potassium 3.8 meq/dl). Abdominal x-ray revealed features of acute intestinal obstruction. With clinical and radiological features of intestinal obstruction due to bezoar, the patient was resuscitated with intravenous fluid and Foley's catheter was put in urinary bladder to monitor urinary output. After proper resuscitation, laparotomy was performed under general anesthesia. Intraoperatively, stomach was distended and filled with plastic fibers forming bezoar [Figure 1]. Stomach bezoar was completely removed via gastrostomy [Figure 2] and rest of the intestine was examined. Another bezoar was found in ileum, one foot proximal to ileocecal junction and it was completely obstructing intestinal lumen [Figure 3]. Intestine was opened at this site, bezoar was removed completely and intestine closed primarily. Other abdominal viscera were normal. Abdominal cavity was lavaged with normal saline and the abdomen was closed in layers. The patient was subsequently discharged on 9 th postoperative day. She was followed-up for a period of 6 months and was put under strict parental supervision.
Discussion | | |
Pica is persistent eating disorder of non-nutritive substances for a period of at least 1 month. It is considered normal for children <2-years-old to put anything in their mouth. After this age, eating non-food items is thought to be abnormal. The cause of pica is unknown, but multifactorial etiology is suggested. Some causes include iron deficiency, psychological factors like poverty, maternal neglect and abuse, lack of parental supervision, disorganized family situation, mental retardation, autism, and brain behavior disorders like Kleine-Levin syndrome More Details. [9],[10],[11] The various non-food items include amylophagia (laundry starch, corn starch), geophagia (clay, sand, and dirt), lithophagia (stones, gravel, and pebbles), pagophagia (ice), trichophagia (hair), and coprophagia (feces). [12] In our case, she was addicted to eating plastic fibers. We can call this "plastophagia".
Bezoars may be composed of hair (trichobezoar), vegetable matter (phytobezoar), milk curds (lactobezoar), sand bezoar [13] and, very rarely, stones (lithobezoar). In our case, bezoar was composed of plastic fibers, hence the term "plastobezoar" was used. Of these bezoars, phytobezoar and trichobezoars are the two most common forms. Bizarre bezoar have developed among partakers of illicit drugs, glue swallower, children or patient with neuropsychiatric disorders who have been known to ingest pins, nail, razor blades, coins, gloves, and even leather wallets. [14] A case has been reported where the child was in the habit of tearing jute fibers from her school bag and eating them, which led to a bezoar obstruction of small intestine, the bezoar being formed mostly of jute fibers. [15] But there are few reported cases of bezoar, containing plastic fibers which have been referred to as plasticobezoar plastobezoar respectively. [16],[17] Around 400 cases of trichobezoar and a larger number of phytobezoars have been reported in the literature but many go unreported. [1],[5] They occur mainly in young women who chew and swallow their hair (trichobezoar) or phytobezoar (vegetable fibers) or pharmacobezoar (tablets/semi liquid masses of drugs). [2],[4],[5],[6],[7],[8] With time, these are retained by mucus and become enmeshed, creating a mass in the shape of the stomach where they are usually found. They may attain large sizes owing to the chronicity of the problem and delayed reporting by the patients. The clinical presentation may be a palpable, firm, non-tender epigastric mass, which is either discovered on routine physical examination in an asymptomatic patient or as intestinal obstruction as in our patient. Bezoars have been reported between the ages of 1 year and 56 years, most presenting between the ages of 15-20 years and 90% are females. Approximately 10% show psychiatric abnormalities or mental retardation. They may also present with gastrointestinal bleeding (6%) and intestinal perforation (10%). [2],[4],[5]
Bezoars mostly originate in the stomach causing non-specific symptoms like epigastric pain, dyspepsia, and post-prandial fullness, the stomach is not able to push the hair or other substances out of the lumen because the friction surface is insufficient for propulsion by peristalsis. [2],[3],[4] Diagnosis at an early stage is important since conservative treatment by fragmentation and endoscopic extraction or enzymatic destruction is possible for gastric bezoars. Rarely the bezoars may extend into the small intestine as a tail (Rapunzel syndrome after "Rapunzel" the fair, long haired maiden in the Grimm brother's fairy tale who lowered her tresses to allow Prince charming to climb up to her prison tower to rescue her) or may get broken lodging in the intestine to cause intestinal obstruction, ulceration, bleeding, and perforation. Small intestinal bezoars have also been reported after truncal vagotomy and with compression of the duodenum by the superior mesenteric artery. [6]
Treatment is removal of the mass by a single enterotomy or by resection of the bowel if not viable. [7],[8] Duncan et al., recommended bezoar extraction by multiple enterotomies in the Rapunzel syndrome. [18] DeBakey and Oschner reported an operative mortality of 10.4%. [19] It is mandatory to do a thorough exploration of the rest of the small intestine and the stomach to look for retained bezoars. If available, endoscopic examination of the stomach is the preferred method of exploring the stomach for the concomitant bezoar while managing a case of intestinal bezoar. Exploration may reveal concomitant gastric bezoar, which may be retrieved endoscopically or by gastrotomy as was done in our patient. Escamilla et al., reported 23 cases of concomitant gastric bezoars (extracted by gastrotomies) out of 87 cases of intestinal bezoars. [8] If detected in the intestine, they may be milked down to the enterotomy site for retrieval through one opening or they may require multiple enterotomies.
Conclusion | | |
In any patient presenting with gastric outlet obstruction, especially at a young age, a detailed dietary and psychiatry history should be taken to rule out possibility of bezoar. Diagnosis at an early stage is important since conservative management by fragmentation and endoscopic extraction or enzymatic destruction is possible for gastric bezoar to avoid laparotomy and operative morbidity and mortality.
References | | |
1. | Sharma RD, Kotwal S, Chintamani, Bhatnagar D. Trichobezoar obstructing the terminal ileum. Trop Doct 2002;32:99-100. |
2. | Andrus CH, Ponsky JL. Bezoars: Classification, pathophysiology, and treatment. Am J Gastroenterol 1988;83:476-8. |
3. | Allred-Crouch AL, Young EA. Bezoars-When the "knot in the stomach" is real. Postgrad Med 1985;78:261-5. |
4. | Goldstein SS, Lewis JH, Rothstein R. Intestinal obstruction due to bezoars. Am J Gastroenterol 1984;79:313-8. |
5. | Senapati MK, Subramanian S. Rapunzel syndrome. Trop Doct 1997;27:53-4. |
6. | Doski JJ, Priebe CJ Jr, Smith T, Chumas JC. Duodenal trichobezoar caused by compression of the superior mesenteric artery. J Pediatr Surg 1995;30:1598-9. |
7. | Santiago Sanchez CA, Garau Diaz P, Lugo Vicente HL. Trichobezoar in a 11-year old girl: A case report. Bol Asoc Med P R 1996;88:8-11. |
8. | Escamilla C, Robles-Campos R, Parrilla-Paricio P, Lujan-Mompean J, Liron-Ruiz R, Torralba-Martinez JA. Intestina obstruction and bezoars. J Am Coll Surg 1994;179:285-8. |
9. | Boris NW, Dalton R. Pica. In: Behrman RE, Klegman RM, Jenson HB, editors. Nelson Textbook of Pediatrics. 17 th ed. New Delhi: Elsevier; 2004. p. 73-4. |
10. | Chatoor I. Feeding and eating disorders of infancy and early childhood. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 8 th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 3217-27. |
11. | Crosby WH. Pica: A compulsion caused by iron deficiency. Br J Haematol 1976;34:341-2. |
12. | Steinberg R, Schwarz M, Gelber E, Lerner A, Zer M. A rare case of colonic obstruction by 'cherry tomato' phytobezoar: A simple technique to avoid enterotomy. J Pediatr Surg 2002;37:794-5. |
13. | Narasimha Rao KL, Chatterjee H, Srivatsava KK, Jayashankarappa BS. Intestinal obstruction due to habit disorder. Indian Pediatr 1983;20:213-4. |
14. | Crawford JM. Gastro intestinal tract. In: Ramji SC, Kumar V, Collins T, editors. Robbins Pathology Basis of Disease. 6 th ed. Harcourt Asia: Saunders. p. 797. |
15. | Mishra SP, Chatterjee K, Gupta NP, Mehrotra Y. An unusal case of intestinal obstruction following a phytobezoar. J Indian Med Assoc 1977;69:13-5. |
16. | Agrawal V, Joshi MK, Jain BK, Gupta A. Plasticobezoar-another new entity for Rapunzel syndrome. Indian J Pediatr 2009;76:229-30. |
17. | Misra SP, Dwivedi M, Misra V. Endoscopic management of a new entity-plastobezoar: A case report and review of literature. World J Gastroenterol 2006;12:6730-3. |
18. | Duncan ND, Aitken R, Venugopal S, West W, Carpenter R. The Rapunzel syndrome. Report of a case and review of literature. West Indian Med J 1994;43:63-5. |
19. | DeBakey M, Oschner A. Bezoars and concretions: A comprehensive review of literature, with analysis of 303 collected cases and presentation of 8 additional cases. Surgery 1939;5:132-60. |
[Figure 1], [Figure 2], [Figure 3]
|