Abdominal imagingCase Type
Marco Lin, Medical Student; Danny Ma, MD Radiologist; Paul Reynolds, DO General Surgery Resident; David Parrish, MD Radiologist; Shivanhalli Prakash, MD General Surgery AttendingPatient
80 years, female
An 80-year-old female presented to the emergency department with lower abdominal pain and vomiting for two days. History was limited due to language barrier. Laboratory tests and physical exams were inconclusive, triggering computed tomography (CT) of the abdomen/pelvis.
Contrast-enhanced CT abdomen/pelvis showed an annular constricting cecal mass with a radiopaque lesion causing partial small bowel obstruction. Also, there were similar appearing numerous round-to-ovoid radiopaque lesions in the dilated distal small bowel. These radiopaque lesions averaged 0.6 cm in diameter, with some containing internal gas. There is no pneumobilia or cholelithiasis.
Bezoars are retained aggregates of indigestible material that accumulate in the gastrointestinal tract. There are four types of bezoars, which are characterized by their components: phytobezoar (fruit and vegetable) which was seen in this case, pharmacobezoar (medications), trichobezoar (hair) and lactobezoar (milk) . Majority of bezoar cases causes obstruction at the rectum [2&3]. Contrasting the norm, this case demonstrated seed phytobezoars trapped near the ileocecal valve due to an obstructing cecal neoplasm.
Seed phytobezoars can be diagnosed clinically with history and rectal exam. However, CT imaging can be useful in the setting of an atypical clinical encounter. Multi-detector computed tomography (MDCT) is typically used to determine the cause, location, and possible complications of bowel obstruction, thus guiding patient management. On CT, seed phytobezoars appear as radiopaque round to ovoid lesions with a hyperdense rim and a more lucent core. The radiolucent core may indicate contained air. Most cases of bezoars are managed through endoscopic extraction alone . However, in this setting of radiographic evidence of cecal malignancy, bezoar extraction in conjunction with surgery, after the appropriate pathologic diagnosis, is the best management.
This patient underwent colonoscopy with biopsy. Intraoperatively, a fungating cecal mass was biopsied, which later demonstrated invasive adenocarcinoma. The patient underwent subsequent right hemicolectomy, partial omentectomy, lymph node dissection, and bezoar extraction. Gross inspection of the resected right colon, ileum, and omentum showed thirty-four intraluminal cherry pit bezoars averaging 0.6 cm and two olive pit bezoars averaging 1.7 cm. One of the twenty-five lymph nodes was positive for metastatic disease.
Taking it all together, phytobezoars may mimic the radiographic appearance of gallstones; however, the absence of pneumobilia is discordant with gallstone ileus. Exuberant quantity of radiopaque findings in the colon may also hint the radiologist to entertain the possibility of foreign body ingestion. Lastly, the majority of bezoars are trapped in the rectum; evidence of bezoars in “atypical” locations, which in this case involved the distal ileum, may prompt the radiologist to investigate for an underlying obstructive lesion. Clinical history, specifically dietary habits, may aid in diagnosis since the majority of phytobezoar cases arises from Mediterranean and Middle Eastern diets . Most causes of bezoars are asymptomatic and are managed conservatively . However, in the setting of bowel obstruction, endoscopic extraction is warranted. Written informed patient consent for publication has been obtained.
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