Figure 1
Plain x-ray upright and supine
A case of small bowel obstruction secondary to santol(Sandoricum koetjape) seed
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsSuman Karki, M.D
Connected authors
41 years, male
Clinical History
A 41-year-old male was admitted due to abdominal distention, vomiting and constipation. He is mentally disabled and has a history of eating santol fruits as mentioned by the relatives.
Imaging Findings
Plain abdomen radiograph in upright/supine position shows gas-filled dilated bowel loops with differential air fluid level in upright view. Small gut obstruction should be considered (Fig.1 a, b).
Plain CT study shows fluid-filled, diffuse moderate dilatation of the small bowels with the largest diameter measuring about 4 cm. Within the dilated small bowel loops there are numerous ovoid hyperdense structures, likely foreign bodies (probably santol seeds), measuring about 2.1 x 1.2cm each. Bowel wall thickening is also seen at the distal ileum, approximately 8cm from the ileocecal junction involving about 9cm in length and measuring about 1.6cm to 2.8cm thick; marked luminal narrowing is noted with a solitary foreign body seen, which was the transition point (Fig. 2 a, b).
Follow-up plain abdomen radiograph in upright/supine position after the conservative management shows minimal interval decrease in the dilated bowel loops and air-fluid levels in the upright view (Fig, 3 a, b).
Plain CT study shows fluid-filled, diffuse moderate dilatation of the small bowels with the largest diameter measuring about 4 cm. Within the dilated small bowel loops there are numerous ovoid hyperdense structures, likely foreign bodies (probably santol seeds), measuring about 2.1 x 1.2cm each. Bowel wall thickening is also seen at the distal ileum, approximately 8cm from the ileocecal junction involving about 9cm in length and measuring about 1.6cm to 2.8cm thick; marked luminal narrowing is noted with a solitary foreign body seen, which was the transition point (Fig. 2 a, b).
Follow-up plain abdomen radiograph in upright/supine position after the conservative management shows minimal interval decrease in the dilated bowel loops and air-fluid levels in the upright view (Fig, 3 a, b).
Discussion
Small bowel obstruction (SBO) is an emergency condition that occurs secondary to mechanical or functional obstruction of the small bowel, preventing normal transit of its contents. It is a frequent cause of hospitalization and surgical consultation, representing 20% of all surgical admissions for acute abdominal pain.
There are several causes of small bowel obstruction. Intraluminal cause, which is less common, is one of them. Among the intraluminal causes of small bowel obstruction (SBO) are gallstones, foreign bodies, retained meconium, bezoars, and tangles of ascarides. Intestinal obstruction caused by a foreign body usually occurs in children or in emotionally disturbed or mentally disabled patients. Santol seeds are one of the causes of SBO in the tropical region [3].
Plain radiography is the initial examination of choice. An intramural width of the small intestine of 3 cm is considered abnormal. However, radiographs are diagnostic in only 50%–60% of cases and have high sensitivity only for high grade obstructions [1].
Ultrasound may clearly demonstrate loops of distended small bowel with hyper peristalsis. Occasionally, the foreign body may be identified on ultrasound as an echogenic intraluminal mass and may cast an acoustic shadow if surrounded by fluid [2]. Sonography is still not a diagnostic modality for the evaluation of the SBO because most of the time, bowels are filled with air producing non diagnostic images.
When plain radiographic findings are inconclusive, abdominal CT is able to correctly reveal the cause of obstruction and preoperative evaluation of SBO, with sensitivity of 90%–96%, specificity of 96%, and accuracy of 95% [1, 2]. CT also helps to demonstrate strangulation, and it is now considered the best modality for determining which patients would benefit from conservative management and close follow-up and which patients would benefit from immediate surgical intervention. In our case, the patient was managed conservatively.
It is also important to look for a transitional point in case of small bowel obstruction.
Most intraluminal causes manifest as endoluminal foreign objects.
In our case, the history of the patient together and the imaging findings helped us come to the conclusion of intraluminal small bowel obstruction secondary to the foreign body (Santol seed); transition point at the ileo-cecal junction. There are also reported cases of bowel obstruction secondary to santol seeds in the prevalent areas. So santol seeds can cause intestinal obstruction when swallowed, and children and mentally disabled patients are more prone to be affected. It should therefore be considered in the diagnosis of bowel obstruction, although it is very rare.
There are several causes of small bowel obstruction. Intraluminal cause, which is less common, is one of them. Among the intraluminal causes of small bowel obstruction (SBO) are gallstones, foreign bodies, retained meconium, bezoars, and tangles of ascarides. Intestinal obstruction caused by a foreign body usually occurs in children or in emotionally disturbed or mentally disabled patients. Santol seeds are one of the causes of SBO in the tropical region [3].
Plain radiography is the initial examination of choice. An intramural width of the small intestine of 3 cm is considered abnormal. However, radiographs are diagnostic in only 50%–60% of cases and have high sensitivity only for high grade obstructions [1].
Ultrasound may clearly demonstrate loops of distended small bowel with hyper peristalsis. Occasionally, the foreign body may be identified on ultrasound as an echogenic intraluminal mass and may cast an acoustic shadow if surrounded by fluid [2]. Sonography is still not a diagnostic modality for the evaluation of the SBO because most of the time, bowels are filled with air producing non diagnostic images.
When plain radiographic findings are inconclusive, abdominal CT is able to correctly reveal the cause of obstruction and preoperative evaluation of SBO, with sensitivity of 90%–96%, specificity of 96%, and accuracy of 95% [1, 2]. CT also helps to demonstrate strangulation, and it is now considered the best modality for determining which patients would benefit from conservative management and close follow-up and which patients would benefit from immediate surgical intervention. In our case, the patient was managed conservatively.
It is also important to look for a transitional point in case of small bowel obstruction.
Most intraluminal causes manifest as endoluminal foreign objects.
In our case, the history of the patient together and the imaging findings helped us come to the conclusion of intraluminal small bowel obstruction secondary to the foreign body (Santol seed); transition point at the ileo-cecal junction. There are also reported cases of bowel obstruction secondary to santol seeds in the prevalent areas. So santol seeds can cause intestinal obstruction when swallowed, and children and mentally disabled patients are more prone to be affected. It should therefore be considered in the diagnosis of bowel obstruction, although it is very rare.
Differential Diagnosis List
Small bowel obstruction secondary to santol(Sandoricum koetjape) seed
Ileus
SBO other than foreign body
Final Diagnosis
Small bowel obstruction secondary to santol(Sandoricum koetjape) seed
References
[1] Ana Catarina Silva, MD, Madalena Pimenta, MD, and Luis S Guimaraes, MD (2009) Small Bowel Obstruction: What to Look For. RadioGraphics 2009 29:423–439 (PMID: 19325057)
[2] Metehan Gumus, Murat Kapan, Akin Onder, Yusuf Yagmur (2011) An unusual cause of small bowel obstruction: dried apricots. JPMA 2011 Nov;61(11):1130-1 (PMID: 22125996)
[3] OMMC Surgery (2015) Santol Seed Causing Intestinal Perforation. http://www.slideshare.net/rjoson/santol-seed-causing-intestinal-perforation-ommc-surgery-march-27-2015
Case information
| URL: | https://www.eurorad.org/case/14072 |
| DOI: | 10.1594/EURORAD/CASE.14072 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 3
Plain x-ray upright and supine
Plain x-ray upright and supine
Plain CT
Plain coronal CT shows diffiusely dilated small bowel loops with several ovoid shaped hyperdense foci, representing foreign body (santol seeds)
DOI, manila med MCM, philippines
DOI, manila med MCM, philippines
Plain axial CT shows a hyperdense focus at the ileo-cecal junction (transition point) with thickening of the ileal wall .
DOI, manila med MCM, manila philippines
DOI, manila med MCM, manila philippines
Plain x-ray upright and supine
Follow-up plain upright abdomnial radiograph shows interval decrease in the dilatation of the small bowel loops
DOI, manila med MCM, manila Philippines
DOI, manila med MCM, manila Philippines
Follow-up plain supine abdominal radiograph shows interval decrease in the dilatation of the small bowel loops. Presence of the rectal gas is seen.
DOI, manila med MCM, manila Philippines
DOI, manila med MCM, manila Philippines