Clinical History
A patient presented with abdominal pain and obstipation in the past five days.
Imaging Findings
The patient was admitted to the Department of Abdominal Surgery complaining of a crampy left side abdominal pain and opstipation that started five days ago. On physical examination a markedly
distended abdomen with generalized tenderness was detected. Rectal examination revealed an empty rectum. His personal history revealed a hospitalization because of acute intestinal obstruction four
years ago. Only plain abdominal film at that time was done without determination of the exact site and cause of obstruction. Emergency laparatomy was performed showing sigmoid colon obstruction due
to phytobezoar. After the surgery he was advised by the dietitian to avoid the food identified to lead to pfytobezoar formation. The recovery was complete. Following his previous history and current
similar clinical feature, barium enema and abdominal CT were performed. Imaging findings of a huge intraluminal mass in the region of the sigmoid colon were strongly suggestive for phytobezoar again.
On CT, similar masses elsewhere within the gastrointestinal tract were not detected. The obstruction was relieved by conservative endoscopic treatment including the use of colonic washouts. It was
followed by passage of a large stool containing numerous undigested fruits and vegetable fibers.
Discussion
Phytobezoar is a rare cause of mechanical intestinal obstruction. They generally occur in the stomach, less commonly in the small intestine and particularly in the colon. The phytobezoar is a
compact mass of fibers, seeds, leaves, roots or stems of plants that collects in the stomach or intestine. Patients who have undergone surgical procedures for peptic ulcer disease or who for other
reasons, such as diabetic gastrointestinal paresis, have a loss of normal pyloric function and decreased gastric acidity are prone to form phytobezoars formation. It is especially common in people
without teeth who cannot chew food thoroughly. Phytobezoars have been reported in diabetics with autonomic neuropathy, in patients with myotonic dystrophy and in patients with delayed emptying of
the stomach secondary to gastric carcinoma. Phytobezoars are rarely found in the intact, normal stomach, except in persons who eat persimmons frequently, have delayed gastric emptying secondary to
anticholinergic therapy or have hypoacidity secondary to cimetidine therapy.
In this case, phytobezoar obstruction of the same intestinal localization was developed two times emphasizing the question why? Why in this healthy man without history of gastrointestinal disorders
as well as some other known diseases or eating of excessive amount of fruit or seeds before and after the onset of symptoms? Why in the same region of the sigmoid colon? The fact that this patient
had a recurrent obstruction constitutes a pathophysiologic dilemma and reinforces the concept that any vegetable matter can form phytobezoars if taken in sufficient quantity and if not prepared or
cooked properly. This case is highlighting the point that an intact gastrointestinal tract does not exclude phytobezoars as a cause of obstruction.
Differential Diagnosis List
Recurrent primary sigmoid colon phytobezoar.
Final Diagnosis
Recurrent primary sigmoid colon phytobezoar.
