Small bowel obstruction caused by phytobezoar and associated with vitamin [B.sub.12] deficiency.

To the Editor: A 57-year-old male patient presented with vomiting 2 hours after a meal; he had also been experiencing abdominal pain, constipation and obstipation for 2 weeks. One week earlier, at another healthcare center, an upper gastrointestinal system endoscopic examination showed phytobezoar at the bulbus, reflux gastritis and gastric ulcer. He had no gastric surgery but had a history of eating persimmons and subclinical diabetes. On physical examination, epigastric tenderness and clapotage was determined. Both erytro-cyte sedimentation rate (68 mm/h) and C-reactive protein were high (52 mg/L). Vitamin [B.sub.12] level was low (130 pg/mL, range 160-900 pg/mL). Plain abdominal radiography showed gaseous distention of the small bowel. Repeated endoscopic examination showed esophagitis stage 2, alkaline reflux pangastritis and gastric and duodenal ulcer. Colonoscopic examination was normal. Electromyogram revealed sensorial and motor polyneuropathy. Abdominal ultrasonography showed dilated small bowel loops and hydropic gallbladder. CT imaging demonstrated a round, het-erogenous, intraluminal-mottled appearance mass, including gas, hyper-dense bodies and soft tissue in the jejunum. The bowel loops proximal to the mass were dilated. Collapsed loops of small bowel were seen immediately beyond this lesion (Fig.). The CT findings suggested an obstructive bezoar. A small bowel barium study showed dilated small bowel loops and a few number of diverticules of the small bowel. Transmission of contrast material was also delayed (approximately 9 hours). During the barium study, defecation of the phytobezoar was observed. The other fragment was defecated just after the study. When the patient was hospitalized, oral uptake was stopped, the nasogastric tube was placed, and medical treatment, including parenteral fluid, pantoprozole, domperidone, ceftriax-one, metronidazole and vitamin [B.sub.12] replacement, was given.

Phytobezoar (a concentration of poorly digested fibers, fruit seeds, pulpy fruits, like oranges and persimmons) is a rare cause of small bowel obstruction. They often form in the stomach, but following fragmentation, they migrate into the small bowel and lead to mechanical obstruction. The main risk factors are abnormal mastication, vegetarian diet, ingestion of persimmons, gastric operation, diabetic gastroparesis and hypothyroidism. (1-3) Plain abdominal radiography may show obstruction occlusive syndrome. However, it is limited in the diagnosis of small bowel obstruction caused by phytobezoars. Barium studies may demonstrate the obstruction and intraluminal-filling defect associated with phytobezoars. Intraluminal tumors, such as adenoma, villous adenoma, leimyosarcoma and metastatic melanoma, cause intraluminal-filling defect and may be indistinguishable from phytobezoars. (2) Computed tomography (CT) has become a useful method in the diagnosis of small bowel obstruction, as it shows the cause, location and degree of obstruction. The most common CT finding of phytobezoars include a round or ovoid mass containing mottled gas at the obstructed site. Dilated loops and collapsed or normal appearing bowel are seen near this obstructed transition zone. (4) The mottled appearance may be similar to small bowel feces sign. However, compared with phytobezoars, this is frequently found within the lumen of a relatively long segment of a dilated small bowel loop. (1) Sometimes a small bowel phytobezoar can be seen as a soft tissue mass without gas and resembles a tumor or intussusception. In this condition, barium studies may be helpful to determine an intraluminal, mobile phytobezoar.

[FIGURE OMITTED]

The treatment of gastric phytobezoars includes enzymatic breakdown and endoscopic fragmentation and removal, whereas small bowel phytobezoars are treated surgically with fragmentation and milking into the cecum. If this is not successful, enterotomy or intestinal resection is performed. (5) In all cases, the stomach should be explored for an additional phytobezoar.

In our case, since previously detected gastric phytobezoar was not removed, it migrated to the small bowel and caused obstruction. Neuropathy associated with vitamin [B.sub.12] deficiency might have added a paralytic component to the mechanical obstruction. CT imaging showed the location of the obstruction caused by a phytobezoar and excluded any other pathology. Medical treatment, including enzymatic breakdown, antibiotics and replacement of vitamin [B.sub.12], was successful, without the need of surgery, when the patient defecated the phytobezoar.

Asli Koktener, MD

Gulcin Dilmen, MD

Department of Radiology

School of Medicine Fatih University

Ankara, Turkey

Cansel Turkay, MD

Mustafa Erbayrak, MD

Department of Gastroenterology

School of Medicine Fatih University

Ankara, Turkey

References

1. Zissin R, Osadchy A, Gutman V, et al. CT findings in patients with small bowel obstruction due to phytobezoar. Emerg Radiol 2004;10:197-200.

2. Verstandig AG, Klin B, Bloom RA, et al. Small bowel phytobezoars: detection with radiography. Radiology 1989;172:705-707.

3. Delabrousse E, Brunelle S, Saguet O, et al. Small bowel obstruction secondary to phytobezoar CT findings. Clin Imaging 2001;25:44-46.

4. Quiroga S, Alvarez-Castells A, Sebastia MC, et al. Small bowel obstruction secondary to bezoar: CT diagnosis. Abdom Imaging 1997;22:315-317.

5. Chilsholm EM, Leong HT, Chung SC, et al. Phytobezoar: an uncommon cause of small bowel obstruction. Am R Coll Surg Engl 1992;74:342-344.

Letters to the Editor are welcomed. They may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See "Information for Authors" for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.