Post Gastrectomy Phytobezoar Causing Intestinal Obstruction
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CASE REPORT
Post Gastrectomy Phytobezoar Causing Intestinal Obstruction Supreet Kaur Grewal1, Rudra Prasad Doley2, Arvind Sahni3, JD Wig2
Abstract Phytobezoars are concretions of vegetable matter in the gastrointestinal tract. Phytobezoars can occur following gastric surgery, owing to altered gastric motility. We report the case of a 60-year-old male with diabetes mellitus (DM), who presented 6 months post distal gastrectomy with small bowel obstruction, due to migration of phytobezoars into the jejunum. He underwent exploratory laparotomy and enterotomy, with the removal of multiple phytobezoars. Key words: Phytobezoar; bezoar; gastrectomy
Introduction Bezoars are concretions of food or foreign material in the gastrointestinal (GI) tract, which occur most commonly in the stomach [1]. Bezoars are classified according to their origin: phytobezoar (undigested fruit or vegetable fibers), trichobezoar (hair), lactobezoar (undigested milk), and pharmacobezoar (medications) [2]. Phytobezoars are known to form following consumption of certain fruits (persimmons, orange and grapefruit pith, etc.) after gastric surgery or gastroparesis [3]. We present the case of a phytobezoar causing small intestinal obstruction, which developed after distal gastrectomy and truncal vagotomy.
Case report A 60-year-old male with diabetes mellitus (DM) presented in the emergency department with a 2-day history of vomiting and abdominal distension. The patient had undergone distal gastrectomy with truncal vagotomy and cholecystectomy for bleeding duodenal and gastric ulcers 6 months previously. He was admitted and resuscitated, and the nasogastric aspirate contained a large amount of food residue. Constrast enhanced computed tomography (CECT) of the abdomen revealed dilatation of the stomach and proximal jejunum, with suspected obstruction of the jejunum (Figure 1). Upper GI endoscopy showed exces-
sive food residue (Figure). Diagnostic laparoscopy was conducted, in view of the unresolving obstruction. Intraoperatively, there were a few adhesions of the jejunum with the parietal wall and omentum. The jejunum was found to be dilated, with a hard mobile intraluminal mass in its proximal part. The laparoscopy, procedure was converted to open surgery to better characterize the mass. Following midline laparotomy, enterotomy was performed in the jejunum and a phytobezoar measuring 5 x 5 cm was delivered (Figure 2). Palpation of the stomach and jejunum revealed and multiple hard masses in the stomach. Multiple bezoars undigested food particles were evacuated from the proximal jejunum and stomach (Figure 3). The enterotomy sites were closed with linear staples. The postoperative course was unremarkable, except for superficial surgical site infection. The patient remains well on follow up.
Discussion Phytobezoars are a rare cause of small bowel obstruc-
1
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India 2 Department of General Surgery, Fortis Hospital, Mohali, India 3 Department of Gastroenterology,
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