REPORTE DE CASO

Terminal ileum perforation secondary to an impacted phytobezoar: case report and review of the literature

Perforación del ileon terminal por un fitobezoar impactado: reporte de caso

HEINZ GEORG HILLER¹, MUSTAFAH RASHID ELAH ABDEL-HALIM,² NICHOLAS RAUL FERNANDO LAGATOLLA^3
1 Vascular surgeon at the Fundación Cardioinfantil, BogotáColombia. heinzhiller@gmail.com
² Surgical registrar at Department of General and Vascular Surgery. Dorset County Hospital, UK
³ Consultant Vascular Surgeon at Department of General and Vascular Surgery Dorset County Hospital, UK

Bezoars are concretions of undigested food particles, medications, milk formulas and hair. The most common presentation of a bezoar is in the form of a phytobezoar, which is caused by precipitation of undigested particles of vegetables and seeds. Small bowel obstruction is mainly caused by adhesions from previous surgery. Of all causes of intestinal obstruction, phytobezoars are responsible for only 0.4-4 % of all causes. They are mainly precipitated by previous strictures caused by surgery, partial gastrectomy, Crohn's disease or intestinal tuberculosis. Symptoms can range from a vague abdominal discomfort to nausea, early satiety, vomiting, halitosis and weight loss. Perforation is a rare complication in an intact abdomen because patients seek early medical treatment before this occurs. We describe the case of an 85 year old male patient, who presented with perforation of the terminal ileum, caused by an impacted phytobezoar and caused a localised abscess that was successfully treated with surgery.

INTRODUCTION

Phytobezoars are the most common form of bezoars in humans and are primarily formed in the ileum, especially in the presence of strictures caused by Crohn's disease, intestinal tuberculosis, previous surgery or even form inside diverticulae. They can also occur in the stomach by the concretion of poorly digested fruit and vegetable fiber predisposed by disturbed gastric motility and decreased acidity in patients after a gastrectomy or vagotomy, and by autonomic intestinal dysmotility in diabetic patients. They are mainly composed of cellulose, hemicellulose, tannins and lignin which can be found in foods such as celery, raisins, prunes, grape skins and most notably persimmons. In high concentrations these foods form a coagulum that upon exposure to and acidic environment begin the formation of a bezoar (4-6).

The most common factors predisposing to the formation of bezoars include previous surgery such as partial gastrectomy and vagotomy and previous small bowel surgery. Medical causes are also associated with this presentation such as hypothiroidism, Guillan -Barre syndrome, diabetes mellitus, cystic fibrosis and psychiatric illnesses with trichophagia (table 2) (7,8).

Clinical manifestations of phytobezoars include chronic indigestion and early satiety and chronic abdominal pain. The most common clinical presentation is a vague epigastric or lower abdominal discomfort. Other symptoms include dysphagia, anorexia, halitosis and weight loss. Of all causes of intestinal obstruction, of which the most common are adhesions. Phyotbezoars account only for 0.4-4 % of all causes and rarely cause perforation. Diagnosis of phytobezoars can be difficult at times, depending on the level of impaction. Clinical examination may reveal a mass at the site of impaction. Plain abdominal films may only show unspecified loops of dilated bowel, and barium studies may show a filling defect as the barium surrounds the bezoar. If the impaction occurs in the stomach, gastroscopy is the method of choice and can be used as a treatment strategy to either fragment or retrieve the bezoar. Abdominal CT scanning has proven useful especially to detect the presence of localised obstruction or perforation (9,10).

We present the case of an 85 year old male patient admitted to hospital with a diagnosis of peritonitis caused by a perforated intestine. During laparotomy the cause was found to be an impacted phytobezoar at the terminal ileum with perforation of the adjacent ileum and abscess formation.

CASE PRESENTATION

An 85 year old male patient was admitted to the emergency department with a three day history of progressive, severe right iliac fossa pain and partial constipation. Previously, he had been suffering of intermittent and self-limiting abdominal pain in the same region. The past medical history included non-insulin dependent diabetes mellitus, chronic atrial fibrillation, hypertension and aortic stenosis with an 80mmHg gradient.

On clinical examination he was dehydrated, with an irregular tachycardia at 103 bpm and normotensive. His abdominal examination revealed a tender, immobile mass in the right iliac fossa. The rest of his examination revealed an ejection systolic murmur, normal respiratory findings and no neurological deterioration. Blood tests revealed a high C-Reactive Protein (313.9 mg/L) in the presence of normal leucocytic count, haemoglobin and serum electrolytes. A plain abdominal film was obtained, which showed small bowel loop dilation with collapsed large bowel and a rounded, radio-opaque shadow projected over the right ileum (Fig 1).

An abdominal CT scan revealed thickening of the terminal ileum, surrounding free peritoneal fluid and a calcified mass in the lumen. The rest of the abdomen was reported as normal. (Fig 2)

Conservative management was initiated with alimentary rest, intravenous fluids and antibiotics, but his signs developed into peritonitis of the abdomen. The patient was taken for a laparotomy, which revealed an abscess in the right paracolic gutter involving the caecum and the terminal ileum. On inspection of the lumen a 3 x 3 cm enterolith was found impacted in the ileocaecal valve causing perforation. A limited right hemicolectomy was performed and sutured with an end to end anastomosis. The patient recovered uneventfully and was discharged after seven days. Histological analysis revealed a phytobezoar, with chronic inflammation of the terminal ileum and caecum. No malignancy or other anatomical anomalies were found.

DISCUSIÓN

The prevalence of bezoars is largely unknown due to the vague clinical presentations especially for a high incidence of sub-diagnosis of the disease. From a surgical point of view, obstruction of any part of the gastrointestinal tract caused by a Bezoar is rare, accounting for only 0.4 to 4 % of all causes of abdominal obstruction. Perforation of the small bowel is even rare because patients usually seek medical advice early in the presentation before this complication occurs. This presentation and perforation of the terminal ileum secondary to a bezoar has been only reported in very few cases (1,2,8).

Typically, the presentation is of a small bowel obstruction that fails to resolve with conservative management. The most common site of obstruction and perforation described in the previous reports, in the absence of any other anatomical precipitants is at the ileo-caecal valve. From our review of articles as far behind a 1993, there are only 17 case reports of obstruction caused by bezoars precipitated by different causes. In one of the larger series of cases by Dirican et al (11) they describe the surgical management of 24 patients in a period of 10 years. The most common cause of obstruction was an impacted bezoar at the site of previous gastric surgery (83.3 %).

In this report, it was clear that CT scanning of the abdomen was able to identify the bezoar causing the obstruction in all patients. Other causes for precipitating obstruction have been described such as a bezoar impacted in strictures caused by Crohn’s disease, (10,12-14); there are two case reports of bezoars causing ileus and obstruction in a Meckel’s diverticulum and a Jejunal diverticulum (in 3 cases) (15-17), and more recently there is a case report by Wilhelmi MH et al. of a phytobezoar in a "healthy adult with a long year history of vegetarian lifestyle" (18).

Perforation of the small bowel caused by an obstructing bezoar is very rare, finding only three reports in the literature since 1993 (19-21). The most plausible explanation for this, is that patients usually seek early medical advice due to the obstructing symptoms, and these perforations occur more due to the impaction of the bezoar and perforation by erosion of the intestinal wall rather than directly through the pressure build up from the obstruction, which is the mechanism underlying the perforation in our case report.

Diagnostic modalities include clinical examination which may reveal a mass in the affected segment in about 30 % of cases, a plain abdominal film which shows only in half of the cases a radio-opaque shadow at the site of obstruction with proximal bowel dilatation. Ultrasound has been evaluated and can be a useful tool in detecting bezoars especially if they are calcified (22). This method, however, is subject to the expertise of the sonographer and the high index of suspicion for the differential diagnosis. More recently, CT scanning of the abdomen reveals more precisely the cause of bowel obstruction with a higher sensitivity and specificity in different case reports (11,23).

Details of the different treatment methods are beyond the scope of this case report but briefly, for bezoars located in the stomach, endoscopic fragmentation or retrieval is the standard treatment. In the cases presenting with distal bowel obstruction and perforation, a laparotomy or a laparoscopic enterotomy is the only available treatment method (10). At operation, patients should be thoroughly assessed for diverticulae and especially strictures associated to Crohn's disease, and tissue samples must be obtained for definitive diagnosis. In our case no anatomical cause was found for the perforation on laparotomy. The presence of the bezoar could only be explained by the patient's diabetes and gastric dismotility and simple impaction in the ileocaecal valve which unfortunately led to perforation of the small bowel. At present only dietary recommendations are made for the long term prevention of this disease.

Obstruction of the small intestine by a phytobezoar is a rare presentation of bezoars of the alimentary tract, but no uncommon, and should be part of the differential diagnosis especially in patients with known predisposing factors. CT scanning of the abdomen remains the most reliable method for diagnosing the presence of a phytobezoar in the digestive tract. At present, surgery remains the mainstay of treating effectively an impacted phytobezoar of the small bowel with or without perforation.

REFERENCES