CASE 13872 Published on 21.07.2016

Small bowel obstruction due to bezoar: a rare cause

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

M.E. Gómez San Martín, I. Jimenez Cuenca, A. Gil Guerra, A. Matilla Muñoz, L. Casadiego Matarranz, M. Pina Pallín.

Hospital de Valladolid
Avenida Ramon y Cajal 3
47005 Valladolid, Spain;
Email:hestergomez17@hotmail.com
Patient

61 years, female

Categories
Area of Interest Abdomen ; Imaging Technique Conventional radiography, CT
Clinical History
The patient presents with acute abdominal pain with no nausea, vomiting or bowel function alteration. The patient mentions two similar episodes, 3 months and 15 days ago, which were resolved with analgesia. Abdominal radiograph and CT confirmed the presence of a phytobezoar in the small intestine, and it was removed in an open laparotomy.
Imaging Findings
- Abdominal radiography: Small bowel loops dilatation with air-fluid levels (Fig. 1).
- Contrast-enhanced abdominal CT:
Dilated stomach and small bowel loops with plenty of liquid content affecting primarily the proximal jejunum and ileum. In the transition between normal calibre and dilated calibre loops there was an image of endoluminal occupation (“small bowel faeces sign”) suggesting the existence of a bezoar (Fig. 2, 3).
Moderate amount of free fluid between handles and lower pelvis. Colon was collapsed.
Discussion
Bezoars may occur in the small intestine or colon, although bezoars are formed mostly in the stomach. However, a part of the bezoar may pass into the small intestine where it may become impacted and cause an obstruction. This is the most common form of presentation, although the bezoar is only responsible for 0.4-4 % of intestinal obstructions. Depending on the location, clinical manifestations vary from no symptoms to acute abdominal pain (feeling of fullness, vomiting, nausea, constipation, symptoms of small bowel obstruction…).

There are different types according to the ingested material: trichobezoars (hair) and phytobezoars (fruit or vegetable fibre) are the most common types. Others may also be formed of drug remains or undigested milk products [1, 2].

There are predisposing factors such as a gastric surgical history (up to 75 %), poor chewing, high-fibre diet, gastric hypokinesia (diabetes), hipoclorhidria, autonomic neuropathy, intestinal disease (TBC, diverticulum, tumour...).

Therapeutically, endoscopic or surgical removal (enterotomy) can be applied.

The main radiological findings are:
• Abdominal radiography: radiolucent spots in the interstices of a solid mass. Indirect signs of intestinal obstruction. When the bezoar is small it is difficult to diagnose through plain X-ray, furthermore they can be confused with abscesses or faeces if located in the colon.
• Sonography: intraluminal hyperechoic mass with convex surface and marked shadowing is suggestive of bezoar. If it is observed in the small intestine, do a differential diagnosis with a possible gallstone ileus which has the same sonographic appearance as an ectopic gallstone. If it is observed in the colon, remember that faecal material can also show this sonographic sign. In the stomach, ultrasound is limited [3].
• Abdominal computed tomography (CT): it is considered the technique of choice for showing the size, location and obstruction or associated complications [4, 5].
The characteristic small-bowel bezoar CT findings are an intraluminal ovoid or round mottled-appearing mass, containing air bubbles and fat density areas inside (“small bowel faeces sign”), in the transition between proximal dilated small bowel loops (diameter > 2.5 cm from outer wall to outer wall) and distal normal calibre loops [ 6, 7].

It is important to differentiate this disease from the faecal material [8, 9]. Bezoars have a well-defined ovoid shape, short length (< 10 cm) and an encapsulated aspect with peripheral wall and fat density inside the lesion. On the contrary, faecal material inside the small intestine is unencapsulated and has a tubular form. Rarely, the bezoar has no air and it is difficult to distinguish from a neoplasm of the small intestine.
Differential Diagnosis List
Obstruction in proximal ileum due to bezoar.
Gallstone ileus
Fecal material inside small intestine
Small intestine tumour
Final Diagnosis
Obstruction in proximal ileum due to bezoar.
Case information
URL: https://www.eurorad.org/case/13872
DOI: 10.1594/EURORAD/CASE.13872
ISSN: 1563-4086
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