A curious case of foreign body induced jejunal obstruction and perforation

Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy

A male patient in his 30s, with myotonic dystrophy (DM), presented to the emergency department with abdominal pain and vomiting. CT imaging revealed a soft tissue lesion in the terminal ileum causing small bowel obstruction (SBO). The patient underwent diagnostic laparoscopy which allowed identification and removal of the obstructing lesion. This was in the form of an intact, undigested potato, a phytobezoar. Bezoars are collections of undigested material found in the gastrointestinal (GI) tract, a phytobezoar is composed of plant material and is the most common form of bezoar. DM is a multisystem disorder characterised by skeletal muscle weakness, however it often presents with GI symptoms and the muscles of mastication are often affected. DM is a known risk factor for bezoar formation and should be considered as an important differential in DM patients presenting with SBO.

A systematic review and risk matrix of plastic litter impacts on aquatic wildlife: A case study of the Mekong and Ganges River Basins

Plastic litter is a pollutant of aquatic environments worldwide, with some of the world's highest litter densities occurring in freshwater ecosystems. Little information about the risk that plastic litter poses to aquatic wildlife is available across the world's most polluted waterways. To help assess the risk to aquatic species where empirical data is lacking, our review presents i) a risk assessment methodology for predicting plastic litter impacts on aquatic wildlife in data poor environments, ii) a case study demonstrating this risk assessment methodology for wildlife across two heavily polluted river basins in Asia, the Mekong and Ganges River Basins; and iii) a broad review summarising common trends in litter interactions and risk to freshwater fish, aquatic birds, cetaceans and raptors. This risk analysis unites a systematic review approach with risk matrices following International Standards Organization's risk assessment criteria, evaluating the risk of plastic entanglement and ingestion and the potential for harm to the animal. In the Mekong and Ganges River Basins, we found that the risk of litter entanglement is higher than litter ingestion. Four species were forecast to be at high risk of entanglement: Ganges River dolphin, Gharial, Mekong giant catfish and Irrawaddy dolphin. The eastern imperial eagle and greater spotted eagle were noted to be at moderate risk of entanglement. Both the Ganges River dolphin and Irrawaddy dolphin were predicted to have a moderate risk of plastic ingestion. Interestingly, cranes, waterfowl and wading birds were deemed at low or negligible risk from plastic litter. This risk matrix methodology can be applied to other waterways and taxa to assess the risk posed by plastic. It can also be readily updated as more information becomes available. This review enables decision makers to bridge a data gap by providing a tool for conservation and management before comprehensive empirical data is available.

A neglected case of chronic abdominal pain due to Lapsi seeds: A unique foreign body at unusual location

•

Chronic partial jejunal obstruction leading to various non specific abdominal symptoms since 40 years.

•

The first reported case of Lapsi seed stones causing partial jejunal obstruction.

•

No change in morphological features of Lapsi seed stones when resided for long within human Gastrointestinal tract.

•

First demonstration of radiological features of Lapsi seed stones both in vivo as well as in vitro.

•

When patient not evaluated by non-physician and non-surgeon could delay diagnosis and improper treatment.

Introduction

Foreign body ingestion is less common in healthy adult population. Obstructive symptom caused by foreign body at unusual site of gastrointestinal (GI) tract is even rarer.

Presentation of case

A 60-year-old female presented to the surgery outpatient department (SOPD) with 40-years of non-specific abdominal pain. Over the years, at various health facilities, multiple abdominal and pelvic ultrasounds were performed. No etiology was identified. A contrast enhanced computed tomography (CECT) of the abdomen found a short segment stricture in distal jejunum and dilated proximal jejunum with multiple hyper dense foreign bodies within the distal part of dilated jejunum. An exploratory laparotomy revealed multiple seed stones of Nepali Hog Plum (Scientific name: Choerospondias axillaris; Nepali Language: Lapsi) resided freely within the dilated and inflamed distal jejunum along with two marked strictures and a narrowed lumen at 7 cm apart at the terminal part of unhealthy jejunum. The seeds were successfully removed and a jejunoileal bypass was performed. The patient had an uneventful postoperative recovery.

Discussion

Lapsi seeds could reside in human gastrointestinal tract for prolonged period and are indigestible in human digestive system that could lead to various inflammatory changes in gastrointestinal tracts causing obstructive symptoms. Widely consumed fruits in Nepal, lapsi seeds when swallowed even by healthy individuals, could effect in gastrointestinal tract.

Conclusion

Lapsi seeds could act as foreign body and obstruct human gastrointestinal tract. Healthcare professionals must approach mystery cases with diligence and thoroughness and timely referral to well equipped center could prevent significant morbidity.