PHYTOBEZOAR SMALL BOWEL OBSTRUCTION ASSOCIATED WITH MECKEL’S DIVERTICULUM: A RARE CASE REPORT

Lai F.*, Baldini A.***, Balzarini B.*,  Franci A.**, Lamia D.**, M.Rugna^**** Magazzini S.*****

* Emergency Department, Ospedale S.Stefano, Azienda USL Toscana Centro, Prato, Italy

** Nurse of Emergency Department, Ospedale S. Stefano, Azienda USL Toscana Centro, Prato, Italy

*** Director of Emergency Department, Ospedale S. Stefano, Azienda USL Toscana Centro, Prato, Italy

 ****M.D. Director SOSD for Territorial Emergency System 118, USL Toscana Centro, Florence, Italy

*****Chief of Emergency Department, Ospedale S. Stefano, Azienda USL Toscana Centro, Prato, Italy

Contacts: dott.francolai@gmail.com

ABSTRACT

Introduction: Phytobezoars are the most frequently observed type and account for approximately 40% of total number of reported bezoars.

Phytobezoar is a trapped mass in the gastrointestinal system, that consists of components of indigestible vegetable material, most commonly from  pulpy fruits, orange pits, seeds, roots or leeves.

Meckel’s diverticulum (MD) is a congenital anomaly due to the presence of a residue of the omphalo-mesenteric duct organized as a diverticulum, a completely blind sac at the ileal level.

The Authors report a rare case of small bowel obstruction due to phytobezoar associated to Meckel’s diverticulum.

 Discussion: Bowel obstruction due to a phytobezoar in a Meckel’s diverticulum is rare: only few cases have been reported in litterature. MD complications are rare and phytobezoar is one of them with only few cases described in litterature.

Keywords: bowel obstruction, phytobezoar, Meckel’s diverticulum, intussusception.

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CASE REPORT

   The Authors describe a 67 years old male presented in Emergency Department (ED) with abdominal pain associated to vomiting, no fever and  no other symptoms were referred.

  The patient referred prior surgery for intussusception in pediatric age.

The  blood pressure was 154/81 mmHg, the heart rate of 70 beats for minute, SpO2 was 98% in room air.

The physical exam showed normal findings for thorax and heart sounds. Abdomen was painful and no peristaltic sounds were present and  was defended.

Blood samples were performed and showed: a normal renal and hepatic function, with normal coagulation pattern, hemochrome showed: WBC 11.9 10^3 µ/L; GR 5.59 10^6 µ/L, Hb 15.7 g/Dl, PLT: 215 10^{^} 3; PCR 0.62 mg/Dl. Sars-COV2 buffer sample was negative.

Blood gas analysis showed normal EAB with a modest ipochloremia.; no methabolic acidosis was present, and lactate showed a normal range as well.

Eco-fast showed normal patterns and no bladder globe.

The strong suspect was related to rule out appendicitis, diverticulitis, cholangitis or cholecystitis, bacterial peritonitis and intestinal perforation. For this reasons was perfomed an abdomen CT scan with intravenous contrast agent which pointed out  in the lumen of distal ileum in the median hypogatsric site the presence of a coarse roundish component with a fecaloid-like appearance (maximum longitudinal extension of 11 cm and maximum axial dimensions of 9 cm) in the first hypothesis bezoar, which determines distension and hydro-aereal levels in the tenual loops upstream to the distal jejunal tract. On the right lateral side of the ileum, at this level, there is a small parietal ejection extended by fluid (likely Meckel’s diverticulum).

CT Scan findings are showed in Figures 1, 2, 3 and 4.

After CT scans a more accurate patient interview reported that the previous day he had eaten two oranges and that he also ate the peel.

Finally a surgical consultation was performed and the patient was admitted in Surgery for small bowel obstruction due to phytobezoar.

DISCUSSION

A bezoar is a tightly packed collection of partially digested or undigested material that most commonly occurs in stomach. Gastric bezoars can occur in all age groups and often occur in patients with behaviour disorders, abnormal gastric emptying, or altered gastrointestinal anatomy. Many bezoars are asymptomatic, but some

cause symptoms. Some bezoars can be dissolved chemically, others require endoscopic removal, and some even require surgery [1].

Bezoars are classified according to their composition:

• Phytobezoars (most common) are composed of indigestible fruit and vegetable matter such as fiber, peels, and seeds.
• Trichobezoars are composed of hair.
• Pharmacobezoars are concretions of ingested drugs (particularly common with sucralfate and aluminum hydroxide gel).
• Diospyrobezoars, a subset of phytobezoars, result from excessive intake of persimmon and occur most often in regions where the fruit is grown.
• Lactobezoars are composed of milk protein.
• Other bezoars are composed of a variety of other substances including tissue paper and polystyrene foam products such as cups.

Phytobezoar: Phytobezoars are the most frequently observed type and account for approximately 40% of the total number of reported bezoars [2].

Phytobezoar is a trapped mass in the gastrointestinal system, that consists of components of indigestible vegetable material, most commonly from pulpy fruits, orange pits, seeds, roots or leeves [3].

Usually a single mass is found but in rare cases multiple masses can also be found.

Symptoms associated with phytobezoar are: nausea, vomiting, abdominal pain, bleeding, gastric outlet.

The bezoarian formationis secondary to:

• Medical conditions that decrease motility in the stomach (gastroparesis)
• Prior gastric surgery
• Decrease of gastric acid secretion/acidity
• Dysphagia (due to loss of teeth, poorly fitting dentures or difficulty in chewing the food properly)
• Weight loss

Diagnosys [4]:

• X-rays
• CT scan
• Abdominal ultrasound
• Endoscopy

Treatment:

Phytobezoar can be treated either medically or surgically. Medical approach consists in administering a large amount of oral liquids in association with antispasmodic agents in case of little bezoar with no signs of bowel obstruction.

Another kind of  treatment for phytobezoar removal consists in using endoscopic approach or extracorporeal lithotripsy.

The risk of using medical treatment is that the procedure may be uncomplete and can expose the patient to iatrogenic complications such as oesophageal-gastric injuries (perforations, bleeding tear, haematoma) or intestinal obstruction due to distal migration of daughter fragments.

Surgical treatment of bezoars is eventually performed by removing the same during gastrostomy and/or enterotomy [5].

Complications: If not treated it may cause gastric ulcers, bleeding, intestinal damage or perforation and bowel obstruction.

Meckel diverticulum (MD): This congenital diverticulum is a slight bulge in the small intestine present at birth and a vestigial remnant of the omphalo-mesenteric duct (also called the vitelline duct or yolk stalk) that ends with a completely blind sac at the ileal level. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms [6].

Most of the population with DM are asymptomatic.

Most common symptoms are rectal painless bleeding, intestinal obstructions, volvulus and intussusception. Occasionally DM may present with acute appendicitis symptoms. It can also present severe epigatsric pain [7].

Diagnosys:

• CT scan
• Angiography
• Abdominal ultrasound
• Accidentally by laparoscopy
•  

Surgical treatment[8]

Frequent complications are rappresented by: Haemorrhage, intestinal obstruction, diverticulitis, umbelical anomalies, neoplasm.

Small Bowel obstruction due to a phytobezoar in a MD is rare (only few cases have been reported in litterature) [9].

The clinical assestment on its own might not be enough to get a correct diagnosis so it is mandatory to arrange several radiological investigations.

CT scan is useful to localize the bezoar as well as to identify bowel obstruction and complications such as perforation.

In the present report the phytobezoar the cause of formation of  bezoar could be due to the relationship between alimentary habits, concomitant presence of MD and prior abdominal surgery for intussusception [10] [11].

From the data obtained by litterature emerges that the possible presence of DM, moreover associated to prior abdominal surgery, predisposes to the formation of phytobezoar and intestinal obstruction [9].

CONCLUSION

A patient with abdominal pain, with previous abdominal surgery, difficulty in chewing, diet rich in fibers and/or delayed gastric emptying comes to their attention; clinicians may suspect that are facing a case of phytobezoar.

Phytobezoar  small bowel obstructions on diverticular malformation and previous gastric surgery are rare clinical events and require prompt and drastic treatment to avoid serious complications, even fatal [2] [12].

The timeliness of diagnostics to be carried out in the emergency room and the collaboration with the specialist surgeon are fundamental for an appropriate and rapid patient care in order to prevent serious complications.

References

[1]	Cifuentes Tebar J, Robles Campos R, Parrilla Paricio P, Lujan Mompean JA, Escamilla C, Liron Ruiz R, Pellicer Franco EM. Gastric surgery and bezoars. Dig Dis Sci. 1992 Nov;37(11):1694-6. doi: 10.1007/BF01299861. PMID: 1425068.
[2]	Bini R, Quiriconi F, Tello A, Fusca M, Loddo F, Leli R, Addeo A. Phytobezoar in Meckel’s diverticulum: A rare cause of small bowel obstruction. Int J Surg Case Rep. 2012;3(5):161-3. doi: 10.1016/j.ijscr.2012.01.006. Epub 2012 Feb 3. PMID: 22382033; PMCID: PMC3316763.
[3]	Chen JH, Chen KY, Chang WK. Intestinal obstruction induced by phytobezoars. CMAJ. 2010 Nov 23;182(17):E797. doi: 10.1503/cmaj.090316. Epub 2010 Jul 19. PMID: 20643839; PMCID: PMC2988565.
[4]	Frazzini VI Jr, English WJ, Bashist B, Moore E. Case report. Small bowel obstruction due to phytobezoar formation within Meckel diverticulum: CT findings. J Comput Assist Tomogr. 1996 May-Jun;20(3):390-2. doi: 10.1097/00004728-199605000-00012. PMID: 8626897.
[5]	Fagenholz, Peter J, and Marc A de Moya. “Laparoscopic treatment of bowel obstruction due to a bezoar in a Meckel’s diverticulum.” JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 15,4 (2011): 562-4. doi:10.4293/108680811X13176785204607
[6]	Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic Correlation. Radiographics. 2004 Mar-Apr;24(2):565-87. doi: 10.1148/rg.242035187. PMID: 15026601.
[7]	Soltero MJ, Bill AH. The natural history of Meckel’s Diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel’s Diverticulum found in King County, Washington, over a fifteen year period. Am J Surg. 1976 Aug;132(2):168-73. doi: 10.1016/0002-9610(76)90043-x. PMID: 952346.
[8]	Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ 3rd. Surgical management of Meckel’s diverticulum. An epidemiologic, population-based study. Ann Surg. 1994 Oct;220(4):564-8; discussion 568-9. doi: 10.1097/00000658-199410000-00014. PMID: 7944666; PMCID: PMC1234434.
[9]	Hussein, Bassem Abou et al. “Phytobezoar impaction in a Meckel’s diverticulum; a rare cause of bowel obstruction: Case report and review of literature.” International journal of surgery case reports vol. 30 (2017): 165-168. doi:10.1016/j.ijscr.2016.10.070
[10]	W. W. e. Morris PJ, Foreign bodies. In: Oxford Textbook of Surgery, 2nd ed., Oxford: Oxford University Press, 2000.
[11]	Van de Steeg LH, Postema RR. Sinaasappelileus bij een Meckel-divertikel [Ileus due to oranges in Meckel’s diverticulum]. Ned Tijdschr Geneeskd. 2012;156(46):A5353. Dutch. PMID: 23151334.
[12]	Pujar K, Anupama et al. “Phytobezoar: a rare cause of small bowel obstruction.” Journal of clinical and diagnostic research : JCDR vol. 7,10 (2013): 2298-9. doi:10.7860/JCDR/2013/7248.3504

A rare case of complete pancreatic fracture in blunt abdominal trauma

F. Lai*, A. Baldini*, C. Pagnini**, L. Pelagatti**, M. Rugna*** S. Magazzini****

*M.D. Emergency Department, Ospedale “Santo Stefano”, Prato, Italy

**School of Medicine, University of Florence, Italy

^*********M.D. Director SOSD for Territorial Emergency System 118, USL Toscana Centro, Florence, Italy

****M.D. Chief Emergency Department, Ospedale “Santo Stefano”, Prato, Italy

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ABSTRACT:  The Authors present a rare case of blunt abdominal injury with pancreatic involvement. We discuss about a 19 years old man who injured his abdomen with bicycle handle-bar.

The Authors report a review of litterature in case of pancreatic  fracture according to American Association for the Surgery of Trauma Classification (AAST) and Wong et al. as well.

Keywords: “Pancreas” or “Pancreatic”, “Traumatic”,  “Transection” or “Fracture” or “Injury*” or “Disruption” or “Grade III Injury”, “Complete”

CASE: J.X. , a 19 year old male, accessed in Emergency Department  (ED) for a blunt abdominal trauma  due to a bicycle handle-bar injury  occurred the day before the clinical evaluation. He presented stable vital parameters (Blood pressure: 119/86 mmHg; Heart rate: 97 bpm; Peripheric saturation: 99% room air), and presented  for localized abdominal pain in epigastrium, exacerbated by palpation. The primary and secondary survey were quite normal. Arterial blood gas analysis showed a normal methabolical and respiratory pattern excepted for lactate who pointed in 2.2 mMol/L (normal values 0.5 – 1.5 mMol/L). Serum Amylase: 63.242 UI/L. Glasgow Coma Scale (GCS) showed 15.

The AMPLE valutation according to Adult Trauma Life Support (ATLS) pointed out any medical or surgical illness.

After clincal examination according to primary and secondary survey we performed an abdominal  CT scan which showed an isolated  post-traumatic complete transection of the pancreas between the body and the tail associated with retroperitoneal hemorragic collection; in addition there was a plentiful hemoperitoneum localized in splenic and pelvic seat as well. (See pictures n. 1-2)

The patient was initially treated with intravenous peripherical  large bore Normal Saline 500 ml (14 Gauge), and supplementary Oxigen. We treated pain with intravenous Tramadol.

Two Red Packed Cells and plasma bag were requested. The patient was admitted in operatory room and treated with a distal pancretectomy and anastomosis with an intestinal loop.

Successively the Patient was admitted in Intensive Care Unit.

EPIDEMIOLOGY: The pancreas is a relatively uncommon organ to be injured in trauma, occurring in less than 2% of blunt trauma cases, and this injury is associated with considerably high morbidity and mortality.^[1] In the pediatric age, Pancreatic injury is rare as it has been reported to occur as low as 0.2% to 1.1% of all trauma. According to other studies, pancreatic injuries has an incidence of 0.4% of trauma presenting in both adult and pediatric populations.^[2-4] Mortality from pancreatic injury has ranged from 9% to 34%. The isolated pancreatic injury is seen in only 30% of cases traumatic pancreatic injury, and only 5% of cases are related to fatal outcomes. Blunt pancreatic trauma is more common in the pediatric population as there is less fat for insulation. ^[5]

DISCUSSION: We have analized only the cases with a Grade of III and a complete transection at the neck of the Pancreas, between the body  and  tail. We haven’t fixed time limits to our research, and the oldest case we have found is of the year 1972

Two patients had a similar presentation to our case (i.e. bicycle handle-bar injury) ^[6]. Frequent trauma related sports: A patient reported trauma during a rugby game ^[7], another during a football match for a trauma with a knee ^[8], an accidental fall from the horse in jumping an obstacle during a horse event ^[9], one during a ski session ^[10], A patient reported a safety belt trauma ^[11] and onother one patient reported a fracture of the pancreas following an aggression ^[12].

DIAGNOSYS: 

• Laboratory findings: serum amylase or amylase in diagnostic peritoneal lavage (DPL) fluid could  be raised and can be useful in diagnosis, but there is poor correlation between amylase and pancreatic trauma because are non-specific^[21]. Amylase in DPL fluid is more sensitive and specific than blood or serum amylase in Pancreatic Trauma.
• RADIOLOGIC STUDIES:  Diagnostic imaging are fundamental  in the recognition, evaluation, grading and follow-up of pancreatic trauma:
• Conventional radiography:  A plain X-ray of the abdomen in patients with pancreatic trauma is nonspecific
•  Ultra Sounds (US)  is easy, portable and economic but pancreatic injuries are difficult to diagnose with these techniques ^[22]. Rather  it is effective in the follow-up of complications such as pseudocysts, frequent after this kind of trauma. Real-time contrast-enhanced US is an useful technique in ED imaging, but its role is not a replacement for CT that remain the first option^[23]
• CT (Computed Tomography) is the gold standard: the fastest, simplest and least invasive (except US) diagnostic technique to show  pancreatic trauma and its complications. The instrumental survey of choice for hemodynamically stable patients is the CT because it provides the safest and most comprehensive means of diagnosis of this kind of trauma ^[24]. CT scans in the pancreatic trauma will point out:
• Frequently (20-40%), when CT is performed within 12 h after trauma, the organ may appear normal because pancreatic trauma  may produce only little changes in the structure which may not be detectable^[25].
• Lacerations are frequent at the junction between  the body and tail due to compression against the spine
• Signs of pancreatic injury are: pancreatic volume focal enlargement, transection, laceration and altered enhancement.
• at the site of laceration or transection we can find hematoma and pseudocysts.
• Other techniques: In the past, ERCP was the only method available for evaluating pancreatic duct integrity even if recently has emerged   MRCP

GRADING: Pancreatic trauma includes a wide range of injuries, from simple contusion injuries (grade I-II) to complete rupture of the pancreatic duct and loss of parenchyma (grade III-V). ^[14] The most used classification is the one proposed by American Association for the Surgery of Trauma (AAST) that includes five different Grade of seriousness. ^[26] (Picture n. 3)

Another classification is the one proposed by Wong et al. : a more simple method for grading severity on CT in pancreatic injury:^[27]

• grade A: pancreatitis or superficial laceration only
• grade B
  • BI: deep laceration involving pancreatic tail

• BII: complete transection of pancreatic tail
• grade C
  • CI: deep laceration involving pancreatic head
  • CII: complete transection of pancreatic head

MEDICAL TREATMENT: The medical treatment of pancreatic trauma has as purpose the containment of the parenchymal damage and to the prevention of septic complications. It constitutes the only treatment practised in case of low-grade injury and in cases under observation. The Basic Treatment of Pancreatic trauma consists of:

• ABCDE valutation and treatment
• Cristalloid infusion
• Bowel rest
• Nasogastric suction
• Nutritional support and  Fluid
• Bladder catheter

Usefully administration drugs are: antienzymes, octreoide, anti H2 drugs, antibiotic, analgesics and parenteral nutrition.^[28]

SURGICAL TREATMENT: Grades I and II treatment consists in non-operative management techniques or simple drainage, whereas  grade III or higher injuries often require resection with possible reconstruction and/or drainage procedures.^[29]

BIBLIOGRAPHY

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Pancreatic trauma: A concise review

Uma Debi, Ravinder Kaur, Kaushal Kishor Prasad, Saroj Kant Sinha, Anindita Sinha, Kartar Singh

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