Phytobezoar: an unusual cause of intestinal obstruction
O Nawawi1MBBS, MRad, FRCR, KL
Ng2MBBS, FRCS, YI Yik2MBBS, MSurg
1 Department of Biomedical Imaging
(Radiology), Faculty of Medicine, University of Malaya, Kuala
2 Department of Surgery, University of Malaya Medical Centre,
Kuala Lumpur, Malaysia
Small bowel phytobezoars are rare and almost always obstructive.
There have been previously reported cases of phytobezoars
in the literature, however there are few reports on radiological
findings for small bowel bezoars. Barium studies characteristically
show an intraluminal filling defect of variable size that
is not fixed to the bowel wall with barium filling the interstices
giving a mottled appearance. On CT scan, the presence of a
round or ovoid intraluminal mass with a ‘mottled gas’
pattern is believed to be pathognomonic. Since features on
CT scans are characteristics and physical findings are of
little assistance in the diagnosis of bezoar, the diagnostic
value of CT needs to be emphasised.
Keywords: Phytobezoars, small bowel obstruction
Phytobezoars are concretion of poorly digested fruit and
vegetable fibres that are found in the alimentary tract, particularly
orange pith or pulp in patients with history of surgery and
persimmon in patients without previous surgery .
Persimmon contains a high concentration of tannin, a monomer
that polymerise in the presence of gastric acid and the polymerized
tannin then acts as a nucleus for bezoar formation.
Previous gastric resection or ulcer surgery such as partial
gastrectomy or truncal vagotomy with pyloroplasty predisposes
to bezoar. Other predisposing factors are ingestion of high
fibre foods, abnormal mastication, diminished gastric secretion
and motility, autonomic neuropathy in diabetic patients and
myotonic dystrophy . Bezoars are currently
regarded as a sequel of gastric surgery and are included in
the postgastrectomy syndromes. Incidence of post gastrectomy
bezoar range between 5-12% . In a normal
stomach, vegetable fibres which cannot pass through the pylorus
undergo hydrolysis within the stomach, which softens them
enough to go through the small bowel. After gastric surgery,
the gastric motility is disturbed and the gastric acidity
is decreased, and the stomach may empty rapidly with an increased
possibility of bezoar formation.
Normally found in the stomach, they may pass into the small
bowel. Primary small bowel bezoar is very rare and is normally
formed in patients with underlying small bowel disease such
as diverticulum, stricture or tumour. Phytobezoar can also
develop secondarily if there are areas of sufficient stagnation
within a dilated bowel segment as may occur in patients with
strictures caused by Crohn’s disease, TB or previous
surgery, or in patients with small bowel diverticula. In such
cases, the bile constituents or calcium salts contribute to
bezoar development .
We present an unusual case of small intestinal obstruction
caused by phytobezoar and discuss the radiological investigations
with special emphasis on CT appearance that leads to the diagnosis
of this condition.
An 81-year-old Chinese woman was referred to our centre from
a private medical centre for further management of intestinal
obstruction and pneumonia. She presented with one week history
of epigastric discomfort associated with vomiting and abdominal
distension. Her bowel habit was mildly altered but there was
no history of passing blood per rectally. She denied any loss
of weight or appetite. Interestingly she gave a history of
eating a large amount of Chinese mushroom a few days prior
to her presentation. Medically she was being treated for hypertension
and congestive cardiac failure. Her past surgical history
consists of a laparotomy performed 26 years ago and a right
nephrectomy for renal stone performed 20 years ago. She was
however unable to ascertain the reason for the laparotomy.
On admission, her vital signs were stable with BP of 200/90
and HR of 100/m. Chest auscultation revealed reduced air entry
and crepitation at the right lower lobe. Her abdomen was soft
but slightly distended. A mobile vague mass was palpable at
the left iliac fossa. Bowel sound was sluggish and per-rectal
examination revealed an empty rectum with no palpable mass.
Her hernia orifice were normal.
Chest radiograph was done and showed right lower lobe consolidation
with evidence of chronic obstructive airway disease and cor
pulmonale. Echocardiogram showed evidence of cor pulmonale
with no acute ischaemic changes. Her blood investigation results
were unremarkable. Blood culture was positive for coagulase
negative Staphylococcus. Urine culture and sputum AFB were
negative. Her amylase level was normal.
Prior to admission to our hospital, the patient had a barium
meal and follow-through examination and CT scan of the abdomen
done at the referring hospital. The barium studies showed
proximal small bowel dilatation with an oval intraluminal
filling defect seen at the end of the dilated segment which
was about 1 foot from the duodeno-jejunal junction. Also present
were ‘coil spring’ and ‘claw’ appearance
which led to the impression of an intussusception (Figure
1). It was reported that there was temporary hold up of contrast
proximal to this level. Her stomach was of normal configuration
and there was adequate gastric emptying. On CT scan of the
abdomen, the filling defect seen in the barium study represented
a hypodense intraluminal ovoid mass with mottled gas pattern
noted within it (Figure 2). There was no obvious site of attachment
to the bowel wall and there was no evidence of whorled appearance
which we would expect to see in intussusception. No other
intraluminal mass or polyps was found, excluding other causes
of obstruction. Bowel distal to the mass was collapsed. The
characteristic CT findings immediately alerted us to the diagnosis
of a bezoar.
Figure 3 Intraoperative findings
of phytobezoar in the jejunum (arrow).
Based on the radiological findings, clinical diagnosis of
bezoar causing partial intestinal obstruction was made and
an exploratory laparotomy with jejunotomy was performed on
the second day of admission. The operation confirmed the clinical
suspicion of a bezoar measuring 5 x 3 cm which was found at
a distance of 34 cm from the duodeno-jejunal flexure (Figure
3). The jejunum was dilated and hypertrophied but there was
no jejunal mass or polyps found. Incidental finding of left
clear looking para-ovarian cyst measuring 4 x 4 cm led to
left salpingo-oophorectomy at the same time.
Pathological report of the operative specimen was degenerate
vegetable matter with no malignancy and a left paraovarian
simple cyst. Post operative period was uneventful, where she
was started on nourishing fluid and soft diet. She was discharged
10 days later with Tab Lisinopril 15mg bd, Tab Unasyn 375mg
bd and Tab Bisolvent 8mg od. She was found to be well during
follow up in surgical clinic one week later.
Small bowel obstruction accounts for 20% of hospital admission.
Common causes are adhesions, strangulated hernia, malignancy,
volvulus and inflammatory bowel disease. Phytobezoars are
rare, accounting for only 0.4 to 4% of all intestinal obstruction.
No particular age or sex prevalence have been observed .
There are 4 types of bezoars. Phytobezoars are the most common,
and are composed of vegetable matter such as celery, pumpkin,
grape skin, prune and persimmons and it contains large amount
of non-digestible fibres such as cellulose, hemicellulose,
lignin and fruit tannins. Trichobezoars are gastric concretion
of hair fibres which usually presents in patients with history
of psychiatric predisposition and in children with mental
retardation. Pharmacobezoars consist of medication bezoars,
which in bulk will adhere, such as cholestyramine, kayexalate
resin, cavafate and antacids. Lactobezoars are milk curd secondary
to infant formula, described in low birth weight neonate fed
on highly concentrated formula within the first week of life
Primary small bowel bezoars almost always present as intestinal
obstruction. They usually become impacted in the narrowest
portion of the small bowel, the commonest site being the terminal
ileum followed by the jejunum , as was
found in our patient. It is interesting to note that more
than half of cases of phytobezoars had history of previous
gastric surgery . Our patient gave a
history of laparotomy done 26 years ago which could be gastrointestinal
Plain radiograph typically shows a classic obstructive pattern.
Occasionally we may be able to see the outline of bezoar,
which is difficult to differentiate from abscess or faeces
within the colon. Ultrasound has been used to detect bezoar.
In a retrospective study done by Ripolles et al. ,
ultrasound was able to detect phytobezoar in 88% of patients
with small bowel obstruction. Bezoar appears as a hyperechoic
arc-like surface with acoustic shadowing on ultrasound, however
this feature may make it difficult to differentiate it from
gallstone which also has similar ultrasound characteristics.
Barium studies characteristically show an intraluminal filling
defect of variable size that is not fixed to the bowel wall.
Barium filling the interstices gives a mottled appearance
similar to that of a villous tumour .
In our patient, the barium study showed an intraluminal filling
defect with a claw appearance giving the impression of an
intussusception. To the best of our knowledge this barium
study finding has not been described by previous reports.
CT scan is fast becoming the first line examination for the
evaluation of small bowel obstruction because it can exclude
other causes of acute abdomen, differentiate between simple
obstruction and strangulation, detect signs of concomitant
intestinal ischemia and can accurately define the cause, degree
and level of obstruction. The presence of round, non-homogenous
mottled mass on CT enabled us to accurately diagnose bezoar
as the cause of intestinal obstruction in our patient. Kim
et al. found that in 11% of the cases, phytobezoar can appear
as a soft tissue mass without gas making diagnosis difficult
as it can resemble an intraluminal tumour or intussusception.
They also described the presence of target sign found in 76%
of their patients caused by mural edema or haemorrhage within
the intestinal wall. The presence of this sign on CT indicates
that the phytobezoar obstructing the bowel may have difficulty
passing through the small bowel lumen. An encapsulating wall
caused by a gel-like membrane covering the bezoar may also
be seen on CT .
According to Andrus et al., endoscopy can definitively diagnose
phytobezoar where it appears as a dark brown, green, black
mass of amorphous material in gastric fundus, antrum or remnant
stomach. They found that barium swallow identified only 25%
of bezoars found endoscopically . Endoscopy
was not necessary in our patient as the bezoar was seen in
the barium and CT examinations.
Small bowel bezoars are treated surgically. It is mandatory
to explore the whole gastrointestinal tract in order to avoid
synchronous bezoar and recurrence of intestinal obstruction
due to retained bezoar. Other treatment options include enzymatic
breakdown and endoscopic fragmentation for gastric bezoar
Recurrence is common unless the underlying predisposing condition
is corrected. Prevention includes avoidance of high fibre
foods, introduction of prophylactic medication to improve
gastric emptying and psychological or psychiatric follow up
in patients with psychiatric disease .
In difficult recurrent cases, periodic endoscopy with repeated
mechanical disruption is warranted.
In conclusion we present an uncommon case of small bowel obstruction
caused by phytobezoar. CT findings can be diagnostic when
there is presence of an intraluminal mass with mottled gas
pattern at the site of obstruction associated with distal
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Received 24 May 2005; received
in revised form 8 August 2005; accepted for publication
16 August 2005
Correspondence: Department of Biomedical Imaging (Radiology), University of Malaya Medical Centre, 59100 Kuala Lumpur, Malaysia.. Tel.: 603-79502069; Fax: 603-79581973; E-mail: firstname.lastname@example.org (Hie-Ching Teng).
Please cite as: Teng HC, Nawawi O, Ng
KL, Yik YI,
Phytobezoar: an unusual cause of intestinal obstruction , Biomed Imaging Interv J 2005; 1(1):e4
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