Colon obstruction due to sunflower seed bezoar: A case report

Abstract

Introduction

This case report aims to present a rare case of colon obstruction caused by a bezoar in a 15-year-old teenager. The significance of this case lies in the rarity of such obstructions and the necessity for early diagnosis and appropriate intervention to optimize patient outcomes.

Presentation of case

A 15-year-old teenager presented with colicky abdominal pain, abdominal distension, nausea, vomiting, and rectal bleeding for three days. Initial investigations yielded normal results, but a digital rectal examination and abdominal X-ray suggested colon obstruction. The patient underwent surgical consultation and emergent laparotomy, during which a bezoar was identified and successfully removed endoscopically. Colonoscopy revealed that the bezoar was composed of shelled sunflower seeds, which correlated with the patient's dietary history.

Discussion

This case highlights the rarity of bezoars causing colon obstruction. Early recognition and appropriate intervention are crucial for optimizing patient outcomes and preventing complications associated with colon obstruction.

Conclusion

This report highlights the importance of considering bezoars as a differential diagnosis in patients with colon obstruction. Early identification and treatment can prevent serious complications and improve clinical outcomes.

Highlights

• •This case report presents a rare instance of colon obstruction caused by a bezoar in a 15-year-old teenager, highlighting an uncommon cause of gastrointestinal obstruction.
• •Initial investigations yielded inconclusive results, underscoring the importance of considering bezoars in the differential diagnosis of colon obstruction, especially in patients with relevant dietary histories.
• •The bezoar was successfully identified and removed endoscopically following an emergency laparotomy, demonstrating the effectiveness of timely surgical intervention in such cases.
• •The bezoar was found to be composed of shelled sunflower seeds, directly correlating with the patient's dietary habits, emphasizing the role of diet in the formation of bezoars.
• •This report emphasizes the need for early recognition and intervention to optimize patient outcomes and prevent potential complications associated with bezoar-induced colon obstruction.

1. Introduction

Bezoars are masses formed by the accumulation of undigested material in the gastrointestinal tract, most commonly in the stomach [1]. They can be categorized into various types, including phytobezoars, trichobezoars, lactobezoars, and pharmacobezoars [2]. Phytobezoars, composed of fruit and vegetable fibers, are one of the most common types and can cause colon obstruction [3]. Risk factors for phytobezoars include excessive consumption of foods with high fiber content and inadequate chewing [4]. Although rare, bezoars should be considered in the differential diagnosis of colon obstruction, especially in patients with relevant dietary habits and risk factors.

2. Case presentation

A 15-year-old teenager presented with abdominal pain, distension, nausea, vomiting, and rectal bleeding, accompanied by signs of dehydration, which collectively defined the unwell state consistent with acute colon obstruction. Although the laboratory findings, including leukocyte count and electrolytes, were within normal limits, the patient exhibited clinical signs of illness such as dehydration, abdominal pain, and distension, consistent with acute colon obstruction. Initial investigations included laboratory tests such as a Complete Blood Count (CBC), Liver Function Tests, Lipase, Urea, and Electrolytes, all of which were within normal limits. Imaging studies, including an abdominal X-ray, revealed multiple dilated loops of the colon with absent rectal gas shadows, consistent with colon obstruction. However, these findings were nonspecific and did not immediately identify the underlying cause. Digital rectal examination provided additional clinical evidence of obstruction, warranting further evaluation with colonoscopy (Fig. 1). The patient underwent surgical consultation and emergency laparotomy due to acute obstruction caused by a bezoar. The bezoar, composed of shelled sunflower seeds, was located in the sigmoid colon, as identified during colonoscopy and confirmed intraoperatively. Intraoperative findings revealed a firm mass in the sigmoid colon causing complete obstruction, without evidence of ischemia or perforation.

Fig. 1.

The figure depicts an abdominal X-ray revealing multiple dilated loops of the jejunum and bowel, conspicuously devoid of gas shadows in the region of the rectum.

Given the patient's acute clinical presentation and unresponsiveness to conservative measures, laparotomy was deemed necessary to prevent complications. During the procedure, the colon was evaluated, and the bezoar was found to be accessible for endoscopic disimpaction. This minimally invasive approach was chosen to avoid the need for enterotomy, thereby reducing the risk of postoperative complications and preserving intestinal integrity. Endoscopic removal was performed successfully under direct visualization, ensuring complete resolution of the obstruction.

This combined strategy of surgical exploration and endoscopic management effectively treated the obstruction while minimizing surgical trauma. A colonoscopy revealed the presence of a bezoar in the colon, obstructing the normal passage of stool and gas. The patient had not passed stool or flatus for over 48 h, indicating constipation. Following the removal of the bezoar, the obstruction was successfully resolved, and the patient experienced the passage of a large amount of flatus and stool of normal consistency. The bezoar was composed of shelled sunflower seeds, correlating with the patient's dietary history.

3. Investigation

Initial investigations were conducted to assess the patient's condition, which included a Complete Blood Count (CBC). Results were within normal limits, ruling out significant leukocytosis or anemia. Urea and Electrolytes were also evaluated, with levels within the normal range, indicating no significant electrolyte disturbances. Additionally, Liver Function Tests and Lipase were performed, and the results were unremarkable, suggesting no acute hepatobiliary or pancreatic pathology. Furthermore, Urinalysis was conducted, which showed no abnormalities, ruling out urinary tract involvement.

4. Differential diagnosis

Given the patient's presentation of central colicky abdominal pain, distension, nausea, vomiting, and rectal bleeding, along with the identification of a bezoar obstructing the big bowel on colonoscopy, colon obstruction caused by a bezoar is the primary consideration. Key features supporting this diagnosis include the presence of a bezoar composed of shelled sunflower seeds, correlating with the patient's reported dietary history. Other mechanical causes of intestinal obstruction should be considered, such as adhesions, hernias, volvulus, or tumors. These conditions may present with similar symptoms of abdominal pain, distension, and vomiting. Differential diagnosis should include evaluating for signs of previous abdominal surgery, abdominal trauma, or risk factors for malignancy [5]. Inflammatory bowel disease (IBD), particularly Crohn's disease, can present with symptoms mimicking colon obstruction, including abdominal pain, distension, and rectal bleeding. However, the absence of chronic symptoms, characteristic inflammatory markers, and radiological findings specific to IBD may help differentiate it from the current presentation [6]. Other gastrointestinal disorders such as appendicitis, diverticulitis, or gastric outlet obstruction should also be considered based on clinical history and imaging findings. Infections such as appendicitis with abscess formation or intestinal tuberculosis can present with symptoms of abdominal pain, distension, and fever. These conditions should be considered, especially in patients with relevant risk factors or epidemiological factors [7]. Given the clinical presentation, imaging findings, and endoscopic evidence of a bezoar, colon obstruction caused by a bezoar remains the most likely diagnosis. However, a thorough differential diagnosis is essential to ensure comprehensive evaluation and appropriate management of the patient's condition.

4.1. Primary treatment

Upon presentation, the patient underwent initial stabilization measures as part of primary treatment to address his condition and facilitate subsequent interventions. These measures encompassed hydration therapy, administration of antibiotics, and the insertion of a nasogastric tube to alleviate bowel distension. Furthermore, surgical consultation was promptly sought to evaluate the necessity for emergent intervention. Subsequently, the patient was expediently transferred to the surgical theater for emergency laparotomy. This work has been reported in line with the SCARE criteria [8,9].

4.2. Secondary treatment

Following the initial stabilization, the patient underwent secondary treatment modalities to address the underlying cause of his symptoms. This involved colonoscopy to identify and remove the obstructing bezoar (Fig. 2). The procedure was performed under sedation, and the bezoar was successfully dislodged using washing, biopsy forceps, and digital disimpaction techniques (Fig. 3). After the obstruction was relieved, the patient experienced the passage of a large amount of flatus and stool (Fig. 4). The successful removal of the bezoar resolved the patient's symptoms and prevented the need for more invasive surgical interventions.

Fig. 2.

The figure illustrates a colonoscopy procedure undertaken due to negative findings on clinical abdominal examination, alongside the presence of rectal bleeding.

Fig. 3.

The figure illustrates the removal of foreign bodies through a combination of washing, biopsy forceps usage, and digital disimpaction performed under sedation.

Fig. 4.

The figure demonstrates the extraction of a significant volume of flatus and stool following the removal of the blockage.

5. Outcome and follow-up

Following the emergent laparotomy and endoscopic removal of the bezoar, the patient experienced a notable improvement in symptoms. Post-operatively, the patient was closely monitored for any signs of complications or recurrence of symptoms. Regular assessments of bowel function, abdominal pain, and overall well-being were conducted during the hospital stay.

During the follow-up period, the patient was advised to adhere to dietary modifications aimed at preventing the recurrence of bezoar formation. Education regarding dietary habits and lifestyle changes was provided to the patient and their family to minimize the risk of future episodes of colon obstruction. Additionally, the importance of maintaining hydration and adequate fiber intake to promote regular bowel movements and prevent bezoar formation was emphasized. Subsequent outpatient visits were scheduled to monitor the patient's progress and address any concerns or complications that may arise.

6. Discussion

Bezoars, though rare, present a unique challenge in clinical practice, especially when they cause small bowel obstruction [10]. In this case, the patient's presentation with abdominal pain, distension, nausea, vomiting, and rectal bleeding prompted thorough investigation to identify the underlying cause. While initial examinations and laboratory tests did not reveal a definitive diagnosis, digital rectal examination and abdominal X-ray provided valuable clues suggestive of colon obstruction.

Phytobezoars, composed of indigestible plant fibers, are one of the most common types of bezoars implicated in small bowel obstruction [11]. They typically form in the stomach but can migrate distally into the small bowel, leading to colon obstruction. Risk factors for phytobezoar formation include excessive consumption of foods with high fiber content, inadequate chewing, and altered gastrointestinal motility. In this case, the patient's history of consuming a large amount of shelled sunflower seeds likely contributed to the formation of the bezoar [12]. Constipation emerged as the most common presenting symptom, indicating the potential for delayed diagnosis across age groups, ranging from 16 months to 79 years.

The clinical presentation of colon obstruction can vary widely, ranging from mild discomfort to severe abdominal pain and vomiting. Physical examination findings may include abdominal distension, hyperactive bowel sounds, and signs of dehydration [13]. Imaging studies, such as abdominal X-ray or CT scan, are often necessary to confirm the diagnosis and assess the severity of obstruction [14]. In this case, abdominal supine X-ray revealed multiple dilated jejunal and ileal loops with absent rectal gas shadows, consistent with colon obstruction.

Management of colon obstruction caused by bezoars depends on several factors, including the patient's clinical condition, the location and size of the obstruction, and the presence of complications such as ischemia or perforation. Conservative measures, such as hydration, bowel rest, and nasogastric decompression, may be initially attempted to relieve symptoms and facilitate passage of the bezoar [15]. However, if conservative management fails or if the patient presents with signs of bowel ischemia or peritonitis, surgical intervention is often required. In this case, the patient underwent emergency laparotomy for definitive treatment, during which the obstructing bezoar was successfully removed endoscopically.

Endoscopic removal of bezoars offers a less invasive alternative to surgery and is particularly useful for small, intraluminal obstructions [16]. Various techniques, including mechanical fragmentation, suctioning, and irrigation, can be employed to dislodge and extract the bezoar under direct visualization [17]. In this case, colonoscopy was instrumental in identifying and removing the bezoar, thereby avoiding the need for more extensive surgical resection.

In the colon, phytobezoars are frequently described at the recto-sigmoid junction or in the sigmoid colon due to the narrow luminal diameter [18]. The literature has documented the cases of phytobezoars with large bowel obstruction, with the majority situated in the sigmoid colon or at the recto-sigmoid junction, followed by occurrences in the right colon and descending colon. Due to the rarity of such cases, there is no universal guideline on management. However, based on the available case reports, conservative or surgical removal is advocated. Endoscopic removal should be attempted where feasible to avoid the morbidity associated with major laparotomy. Attempts at dissolution of the bezoar with chemical agents such as papain, cellulose, and acetyl cysteine have been described with variable success. In cases where conservative methods fail or the patient presents with an acute abdomen, exploratory laparotomy remains a viable option.

This case highlights the importance of considering dietary habits and risk factors in the diagnosis and management of colon obstruction caused by bezoars. Clinicians should maintain a high index of suspicion for bezoars in patients presenting with relevant symptoms, especially in those with a history of consuming high-fiber foods like sunflower seeds. Early recognition and appropriate management are essential to prevent complications and ensure optimal patient outcomes.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The study is exempt from ethnical approval in Kerman University of Medical Sciences.

Sources of funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Author contribution

O. E: Conceptualization, Methodology, Data curation, Patient management, Supervision. S.M.KH: Writing - Original draft preparation, writing, editing.

Declaration of competing interest

All authors declare no conflict of interest.