A 62-year-old woman with a history of hypertension, type II diabetes mellitus, and chronic constipation presented to the emergency department complaining of severe tenesmus, anal pain with the passage of small amounts of blood-tinged watery stools of 3 days’ duration. For the past few weeks prior to presentation, she had been on a special diet for the purpose of weight loss and improving her diabetes. This diet constituted of daily pomegranate and clear liquids. Digital rectal examination revealed fecal impaction with hard, sharp seeds. Manual disimpaction was attempted, and these seeds turned out to be pomegranate seeds. The patient was discharged home but returned the next day after being unable to defecate. Digital disimpaction failed due to the huge amount of impacted seeds. Sigmoidoscopy revealed impacted pomegranate seeds that could not be mobilized with water jets or forceps (Figures 1A–D). The patient was referred for surgical management. She underwent examination under anesthesia with the removal of impacted seeds that had reached the sigmoid colon. She was discharged home postoperatively.
Figure 1.
Sigmoidoscopy showing impacted pomegranate seeds.
Seed bezoars are a very uncommon cause of fecal impaction in humans. Till the present day, only 2 papers of fecal impaction due to pomegranate seeds have been reported.1,2 Eitan et al reported 30 cases of phytobezoars leading to fecal impaction including the first case due to pomegranate seeds. All 30 patients were treated with manual disimpaction under general anesthesia due to the severe pain.1 The second reported case was a middle-aged man, who also treated with manual disimpaction.2 Our image represents the third case in the published studies and provides endoscopic images captured during the sigmoidoscopy. The phenomenon of fecal impaction is mostly noted in the Middle East (specifically in Arab countries) due to the eating habits of fruits with their seeds. The treatment of rectal impaction due to seed bezoars is usually manual disimpaction under general anesthesia. The use of general anesthesia during disimpaction is crucial to relax the anal sphincter, disimpact in a single procedure, and thus avoid sphincter injury.
REFERENCES
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