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Abdominal pain, nausea, and vomiting in a 10-year-old girl.

A 10-year-old white girl was brought to the emergency department by her parents for extreme abdominal pain, nausea and vomiting Nausea and Vomiting Definition

Nausea is the sensation of being about to vomit. Vomiting, or emesis, is the expelling of undigested food through the mouth.
, and decrease in appetite. The patient's mother said she began complaining of the pain the previous morning and the pain was progressive throughout the day and night, eventually leading them to bring the child to the emergency room at about 2:00 am. At that time, the patient was tachycardic and in extreme pain. She had a white blood cell count white blood cell count,
n a diagnostic clinical laboratory test to determine the number and types of leukocytes present in a measured sample of blood. Overall the normal number of leukocytes ranges from 5000 to 10,000/mm3.
 of 18.9 x [10.sup.3]/[micro]L. A computed tomography (CT) scan was done (Figures 1-3).

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What is the diagnosis?

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DIAGNOSIS: Small bowel obstruction with sunflower seed bezoar bezoar /be·zoar/ (be´zor) a concretion of foreign material found in the gastrointestinal or urinary tract.

be·zoar
n.
. Multiple unshelled seeds were seen elsewhere throughout the intestine (Figures 4 and 5). After the CT scan was performed, further clinical history was elicited, and the child said that she had been eating sunflower seeds for the past 2 days. The exact volume of seeds was unknown.

The operative report described a complete small bowel obstruction with a transition point just distal to a palpable intraluminal mass. The intraluminal mass was solid and freely mobile. The mass was easily "milked" forward through the distal small intestine and into the cecum cecum (sē`kəm): see intestine. . No residual mass, adhesion, intussusception Intussusception Definition

Intussusception is the enfolding of one segment of the intestine within another. It is characterized and initially presents with recurring attacks of cramping abdominal pain that gradually become more painful.
, or anatomical abnormality was found. The mass eventually passed through the colon postoperatively without any diffi culty. No enterotomy en·ter·ot·o·my
n.
An incision into the intestine.



enterotomy

incision of the intestine.
 was needed. Small bowel obstruction with sunflower seed meat bezoar was diagnosed postoperatively.

DISCUSSION

A bezoar is a mass of indigestible or poorly digestible material that forms within the digestive tract. Bezoars often lead to intestinal obstruction, as in our patient. The specific type of bezoar seen in this case was phytobezoar, which comprises plant material such as vegetable or fruit fibers or seeds. Other types of bezoars include trichobezoar, composed of hair, and lithobezoar, composed of hard concretions such as small stones or pebbles.

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Clinically, these patients often present with signs and symptoms of bowel obstruction. A palpable abdominal mass is occasionally found. Upon rectal examination, the presence of the "colonic crunch sign" can increase the suspicion of bezoar obstruction. The colonic crunch sign is defined as the palpation of a prickly mass on digital rectal examination Digital rectal examination
A routine screening test that is used to detect any lumps in the prostate gland or any hardening or other abnormality of the prostate tissue.
 and can be found in sunflower seed bezoar and lithobezoar (1).

Intestinal obstruction with sunflower seed bezoar is not uncommon, and several case reports have been published. One study from Israel found that seed bezoars found in the rectum were the most common cause of fecal impaction requiring hospitalization (2). Caution is advised in allowing young children to consume seeds if they are unable to shell and chew the seeds prior to ingestion. Also, dietary consumption of unshelled seeds or seeds with shell fragments should be accompanied by an awareness that large quantities may lead to phytobezoar formation and intestinal obstruction.

Acknowledgments

The author thanks Dr. Mark Fulmer and Dr. Valerie Gorman for providing the case for report.

(1.) Melchreit R, McGowan G, Hyams JS. "Colonic crunch" sign in sunflower-seed bezoar. N Engl J Med 1984;310(26):1748-1749.

(2.) Eitan A, Bickel A, Katz IM. Fecal impaction in adults: report of 30 cases of seed bezoars in the rectum. Dis Colon Rectum 2006;49(11):1768-1771.

William G. Schucany, MD

From the Department of Radiology, Baylor University Medical Center, Dallas, Texas.

Corresponding author: William G. Schucany, MD, Department of Radiology, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246 (e-mail: gschucany@americanrad.com).
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Title Annotation:Radiology Report
Author:Schucany, William G.
Publication:Baylor University Medical Center Proceedings
Article Type:Case study
Geographic Code:1USA
Date:Apr 1, 2009
Words:583
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