Small bowel obstruction secondary to crab shell bezoar: A case report

Small bowel obstruction is a common surgical condition that needs surgical intervention if conservative measures fail. Bezoar is a rare aetiology of small bowel obstruction with incidence of 4.5%. The bezoars can be grouped, according to the content, into four common types: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars. However, unusual bezoars like plastic bezoars and metal bezoars have been reported too. Herein, we report a case of an elderly lady who was treated for small bowel obstruction due to crab shell bezoar. This is the first case reported in literature. Ingestion of large intact pieces of crab shell should be avoided due to the potential of causing small bowel obstruction.

Tannin-phytobezoars with Gastric Outlet Obstruction Treated by Dissolution with Administration and Endoscopic Injection of Coca-Cola®, Endoscopic Crushing, and Removal (with Video)

A 77-year-old man complained of postmeal vomiting and sustained general fatigue. An abdominal computed tomography scan showed massive gastric expansion and fluid storage. Gastroscopy revealed four gastric bezoars that were considered to have caused pyloric ring obstruction. The patient was asked to drink 500 mL per day of Coca-Cola^® for 4 days. On the fourth day, we performed endoscopic crushing and removal by injecting Coca-Cola^®, cutting the softened bezoar with endoscopic snares, and collecting the pieces with endoscopic nets. We herein report (with a video presentation) a rare case of tannin-phytobezoars endoscopically removed with the administration and injection of Coca-Cola^®.

Gastric perforation secondary to Rapunzel syndrome

Rapunzel syndrome is rare and describes a trichobezoar that extends through the pylorus into the jejunum, ileum or even the colon. Due to the large intraluminal size and weight they can attain, acute presentations of obstruction or perforation may occur. We report a case of a 17-year-old girl who presented to the emergency department following a syncopal episode. On examination, a left upper quadrant mass was appreciated with no signs of peritonism. Contrast-enhanced CT demonstrated a giant trichobezoar with resulting gastric perforation and intra-abdominal free fluid. Laparotomy and gastrotomy were performed and the patient had an uneventful recovery with psychiatric review prior to discharge. Though uncommon, bezoars should be included in our differential diagnosis as they can present in various ways owing to their size and weight. This case illustrates the risk of gastric perforation with large gastric bezoars.

Ileal Ulcer Associated With a Large Bezoar Mimicking Malignancy on FDG PET/CT

A 34-year-old woman presented with abdominal pain for 2 months. Abdominal CT revealed a large bezoar in the distal ileum with surrounding thickened ileal wall and enlarged mesentery lymph nodes. On FDG PET/CT, the thickened ileal wall and enlarged mesentery lymph nodes showed increased FDG uptake. Ileal malignancy with mesentery lymph node metastasis was suspected. The distal ileum and enlarged mesentery lymph nodes were removed. Benign ileal ulcer and mesentery reactive lymphoid hyperplasia were confirmed by histopathology.

Trichobezoar

BACKGROUND

Rapunzel syndrome refers to a gastric bezoar with post-pyloric extension.

CASE PRESENTATION

A child of primary school age presented with four days of abdominal pain, nausea, vomiting and a non-tender palpable mass in the upper part of the abdomen. The child had a history of trichotillomania and trichotillophagia. Preoperative imaging including abdominal ultrasound and upper gastrointestinal series was suggestive of gastric bezoar extending into the duodenum. At laparotomy and gastrotomy a large trichobezoar which had taken the shape of the stomach with a 60 cm long tail extending into the jejunum was removed. The child had an uneventful recovery and was discharged home on the fifth postoperative day.

INTERPRETATION

Although rare, trichobezoar should be considered as a differential diagnosis for abdominal pain in young patients with a known history of trichotillomania and trichotillophagia.

Multiple small bowel perforation in a young adult female due to Rapunzel Syndrome

INTRODUCTION

Rapunzel's syndrome is the state of the gastric trichobezoar (hair ball) extending to the small intestine. Although it is seen very rarely, it is a psychiatric and mental illness especially in young women. We present here, a young female with recurrent trichotillomania.

CASE PRESENTATION

In a 24-year-old patient who underwent laparotomy due to recurrent trichobezoar, which completely filled the stomach and extended to the small intestine, caused perforation in two places in the small intestine, was removed by gastrotomy and enterotomy. One of the perforated areas was very close to ligament of Treitz, and perforation occurred due to the ulcer caused by trichobezoar. Post-operative central total parenteral nutrition was given and oral intake was started at the end of the first week. The patient was referred to psychiatry and antipsychotic medication was started. She was discharged on the 9th postoperative day without any problem.

CONCLUSION

Although there are no signs of peritonitis in such Rapunzel syndrome cases, a detailed exploration should be made by keeping in mind that trichobezoar will cause ulceration and perforation. In addition, as the primary cause is the underlying psychiatric disorder, patients should be referred to the psychiatry clinic to prevent recurrence.

KEY WORDS

Adult, Rapunzel syndrome, Surgery, Trichobezoar, Trichotillomania.

The cause of abdominal mass in a child with celiac disease: Rapunzel syndrome. A case report

CONTEXT

Rapunzel syndrome is a rare form of gastric trichobezoar that develops through outstretching of the bezoar from the stomach to the intestine.

CASE REPORT

A 12-year-old girl who had been diagnosed with celiac disease six years earlier was brought to the department of pediatric gastroenterology because of abdominal distension. A palpable mass was detected. A trichobezoar that stretched to the small intestine was removed surgically. The patient was diagnosed as having anxiety and depressive disorder, and treatment started. Following the treatment, her previous trichophagia completely disappeared.

CONCLUSION

Presence of trichobezoar should be kept in mind, especially when young girls who have psychiatric problems suffer from gastrointestinal symptoms.

[Giant Rapunzel syndrome with atypical complication. Report of a case]

Rapunzel syndrome is an unusual and rare form of gastric trichobezoar that extends into the small intestine. The formation is due to the continuous ingestion of hair which leads to the impaction of the hair along with mucus and food, but it is rare that gastric perforation occurs. We report the case of a female patient of 16 years of age admitted to our institution with a history of depression and clinical symptoms characterized by nausea, severe epigastralgia and pathological loss of weight. The physical examination showed a tense abdomen with a peritoneal reaction. Contrast-enhanced tomography showed a distended stomach with a heterogeneous content that extended to the duodenum, hydro pneumoperitoneum, Douglas sack bottom liquid, and it was decided to perform an exploratory laparotomy. Showed perforation in the anterior face of the stomach which is infrequent, so we proceeded to the extraction of giant trichobezoar with duodenal extension; Evolving favorably, the patient being referred to outpatient controls with psychiatry; Finally, a high endoscopy was performed at 6 months, which evidenced the scar of the surgical procedure.

Fungaemia caused by obstructive renal candida bezoars leads to bilateral chorioretinitis: a case report

BACKGROUND

Renal fungal bezoars are remarkably rare and mostly occur in immunodeficient patients. Only a small number of cases with immunocompetent patients have been published so far. The published treatment approaches comprised systemic antimycotic therapy and surgical or minimal invasive removal of the fungal balls. In some cases irrigation of the renal duct system with amphotericin B was performed. By obstruction of the urinary tract bezoars can lead to infected hydronephrosis and severe urosepsis with high lethality. Fungaemia can cause fungal colonization in different distant organs. Fulminant chorioretinitis and irreversible visual impairment can be the consequence of ocular fundus colonization. The following report highlights that a co-operation between urologists and ophthalmologists is absolutely indispensible in case of fungaemia.

CASE PRESENTATION

Hereinafter we describe a case of an immunocompetent 56 years old woman, presenting with flank pain and shivering. The diagnosis turned out to be difficult due to initially negative urine culture. The fungaemia caused by obstructive nephropathy led to bilateral candida chorioretinitis. The patient was treated with intravenous amphotericin b and the bezoar was removed by percutaneous "nephrolitholapaxy". After two months, a follow up revealed the patient felt well, chorioretinal lesions regressed and urine culture did not show any fungal growth.

CONCLUSION

To the best of our knowledge, this is the first case reporting on obstructive renal bezoars, which lead to haematogenous fungus spread and bilateral chorioretinitis. It points out that extensive ophthalmologic examination should be performed in case of fungaemia even if the patient is not suffering from any visual impairment.

An unusual enterolith ileus

The duodenum is an uncommon location of diverticula in the digestive tract, and they are often asymptomatic. Formation of an enterolith inside diverticula has been previously described, although it is a rare condition. In this context, intestinal obstruction due to distal migration of foreign bodies is extremely rare. We report a case of an 86-year-old woman with obstructive symptoms due to a jejunal foreign body that had migrated from a duodenal diverticulum. An emergency laparotomy was performed to extract a phytobezoar. Enterolith ileus secondary to duodenal diverticula is an exceptional entity. Diagnosis and management are usually delayed because of a non-specific presentation, and early surgical exploration is required for bowel disimpaction. This condition should be considered in elderly patients with prolonged immobilization or neurodegenerative diseases.

Delayed diagnosis of trichobezoar in a patient with presumed anorexia nervosa

Anorexia nervosa is a medical and psychological disorder classically seen in young women who present with significant weight loss, a distorted body image, and an intense fear of gaining weight despite being underweight. A rare diagnosis that is also associated with weight loss is a trichobezoar, a collection of hair or hair-like fibers in the gastrointestinal tract, primarily in the stomach. In this report, we present the case of a 14.5-year-old girl with weight loss caused by a trichobezoar, initially thought to be due to anorexia nervosa, and we review the details of both disorders.

Gastric Outlet Obstruction--An Unexpected Complication during Coca-Cola Therapy for a Gastric Bezoar: A Case Report and Literature Review

Gastric bezoars are concretions of undigested material, and Coca-Cola therapy is an easy, efficacious and safe approach for bezoar treatment. Gastric outlet obstruction due to a migratory gastric bezoar during Coca-Cola therapy is an uncommon presentation and, to the best of our knowledge, no cases have been previously reported. We herein describe one such case with no known predisposing factors that recovered via the endoscopic technique. A thorough literature search was performed, which yielded eight relevant patients from seven publications, all of who developed gastrointestinal obstruction during dissolution treatment and recovered uneventfully after surgical intervention. In conclusion, this potential complication should be kept in mind in the event that alternative treatment is necessary.

Bezoar-induced small bowel obstruction: Clinical characteristics and diagnostic value of multi-slice spiral computed tomography

AIM: To determine the possible predisposing factors of bezoar-induced small bowel obstruction (BI-SBO) and to discuss the diagnostic value of multi-slice spiral computed tomography, particularly contrast-enhanced scanning, in this condition.

METHODS: A total of 35 BI-SBO cases treated at our hospital from January 2007 to December 2013 were retrospectively analysed. Complete clinical and computed tomography (CT) data of the patients were available and confirmed by surgery. SBO was clinically diagnosed on the basis of clinical manifestations. Of the 35 patients, 18 underwent abdominal and pelvic CT planar scanning with GE 64-slice spiral CT and 17 underwent abdominal and pelvic CT planar scanning with GE 64-slice spiral CT combined with contrast-enhanced examination. Original images were processed using a GE ADW4.3 workstation to obtain MPR, CPR, MIP and CTA images. The images of all patients were evaluated by two abdominal imaging experts. The main analytical contents of planar scanning included intestinal bezoar conditions, changes in the intestinal wall and changes in peri-intestinal conditions. Vascular hyperaemia and arterial blood supply conditions at a specific obstruction site and the distal end of the obstruction site were evaluated through contrast-enhanced examination.

RESULTS: The proportion of males to females among the 35 cases was 1:1.69 (13:22); median age was 63.3 years. The following cases were observed: 29 (82.8%) cases occurred in autumn and winter and showed a history of consuming high amounts of persimmon and hawthorn; 19 (54.3%) cases revealed a history of gastrointestinal surgery; 19 exhibited incomplete dentition, with missing partial or whole posterior teeth; 26 suffered from obstruction at the ileum. A total of 51 bezoars were found in these patients, of whom 16 (45.7%) had multiple bezoars. CT planar scanning of bezoars showed lumps with mottled gas inside the intestinal cavity. Furthermore, 9 cases of bezoars had envelopes and 11 cases were accompanied with thickening of the distal wall of the obstructed bowel. Scanning of 17 cases was enhanced; the results revealed that the mesenteric blood vessels at the obstruction site and the proximal site were dilated, and a total of 7 cases were accompanied with distal vascular dilation and intestinal wall thickening.

CONCLUSION: BI-SBO exhibits regional and seasonal characteristics. CT planar and contrast-enhanced scanning can be applied to diagnose and observe vascular conditions in obstructed zones.

RECTAL IMPACTION DUE TO PRICKLY PEAR SEEDS BEZOAR: A CASE REPORT

Fecal impaction is the third cause of lower gastrointestinal tract obstruction after strictures for colon cancer and postoperative adhesions. A rapid diagnosis is necessary to avoid complications due to intestinal obstruction. Rectal phytobezoar due to prickly pear fruit seeds are an extremely rare entity, in the literature about twenty similar cases are described. Prickly pears are common in many countries, even in the Mediterranean area. When the ingestion of their fruit is excessive, this can be harmful, leading to the formation of phytobezoar causing fecal impaction. We describe the first case of phytobezoar due to prickly pear fruit seeds in continental Europe: a 76-year-old Italian female who ingested almost 40 prickly pear fruit leading to the composition of a large rectal phytobezoar. The patient presented clinically with fecal impaction, diagnosed by imaging and successfully treated by rectal irrigation and manual disimpaction. Our aim is to remind the physicians of these risks in evaluating patients with intestinal obstruction, when there is positive anamnesis for provenience from some areas in which these fruits are eaten. We also want to underline the role of Imaging Multi Detector Computed Tomography (MDCT) in the diagnosis of these very uncommon entities.