|Year : 2013 | Volume
| Issue : 4 | Page : 285-287
Phytobezoar at the Meckel's diverticulum presenting as small bowel obstruction: A rare case
Hari Prasad Ballapalli, Mallikarjun V Telsang, Anusha Arumalla
Department of General Surgery, Kamineni Institute of Medical Sciences, Narketpally, Andhra Pradesh, India
|Date of Web Publication||26-Nov-2013|
Hari Prasad Ballapalli
Department of General Surgery, Kamineni Institute of Medical Sciences, Narketpally - 508 254, Nalgonda (Dt), Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Meckel's diverticulum occurs in about 1-3% of the general population. The majority of them are asymptomatic and incidentally identified at laparotomy. The most common complication due to Meckel's diverticulum in adults is intestinal obstruction. Phytobezoar is a concretion of poorly digested fruit and vegetable fibres that is found in the stomach commonly causing symptoms varying from dyspepsia to epigastric mass. Phytobezoars can rarely cause small intestinal obstruction. Herein, we have reported a case of phytobezoar in Meckel's diverticulum presenting as small bowel obstruction in a 38-year-old female.
Keywords: Meckel′s diverticulum, phytobezoar, small bowel obstruction
|How to cite this article:|
Ballapalli HP, Telsang MV, Arumalla A. Phytobezoar at the Meckel's diverticulum presenting as small bowel obstruction: A rare case. J NTR Univ Health Sci 2013;2:285-7
|How to cite this URL:|
Ballapalli HP, Telsang MV, Arumalla A. Phytobezoar at the Meckel's diverticulum presenting as small bowel obstruction: A rare case. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Apr 4];2:285-7. Available from: http://www.jdrntruhs.org/text.asp?2013/2/4/285/122173
| Introduction|| |
Meckel's diverticulum is an embryological residue resulting from an incomplete obliteration of vitelline duct during the fifth week of gestation. It was described in 1598 by the German surgeon Wilhelm Fabricius Hildanus; ,, it was studied in 1809 under the embryological and anatomical profiles by Johann Friedrich Meckel. The complications occurring in Meckel's diverticulum, such as hemorrhage, perforation, and pancreatitis, are due to the presence of such heterotopic tissues. Intestinal obstruction is one of the complication of Meckel's diverticulum. This complication generally is due to a volvulus of a small bowel loop around a cord or a fibrous band that fixes the diverticulum to the abdominal wall or to intestinal intussusception. The occurrence of small bowel obstruction due to a phytobezoar within a Meckel's diverticulum is very uncommon and seldom reported. 
| Case Report|| |
The case patient was a 38-year-old female patient with complaints of pain and distension of abdomen since past 4 days. History of two episodes of bilious vomiting was reported as well as along with a history of inability to pass stools and flatus since past 1 day. Patient had consumed 5 raw mangoes the previous day before the symptoms started. The patient had undergone LSCS, but no other surgical history. The patient has no history of any behavioral problems or any significant drug history.
On clinical examination, the patient was conscious and coherent. Signs of dehydration were present and pulse was 98/min and blood pressure was 100/70 mmHg. Abdomen was distended and bowel sounds were exaggerated. Per rectum was empty. X-ray abdomen in erect and supine positions showed features of small bowel obstruction [Figure 1]. Ultrasound abdomen showed dilated bowel loops and minimal free fluid in abdomen.
|Figure 1: X-ray abdomen in erect position showing multiple air fluid levels in the small bowel and absence of air in the large bowel|
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A diagnosis of small bowel obstruction was believed to be the cause probably because of the adhesion bands. The patient was taken for emergency laparotomy. Intraoperatively dilated jejunal and ileal loops were seen with large Meckel's diverticulum with stalk and the distal intestinal loops were collapsed [Figure 2]. No evidence of any gangrenous changes were noticed. A mass was palpated in the small bowel at the region of Meckel's diverticulum causing obstruction. A resection and anastomosis was done, and undigested food residue were observed on opening the specimen phytobezoar [Figure 3].
|Figure 2: Dilated bowel loop at the region of Meckel's diverticulum and collapse of the bowel distal part to the obstruction and dilated bowel proximal to the obstruction site|
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|Figure 3: Specimen cut open containing undigested plant matter (phytobezoar)|
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| Discussion|| |
Meckel's diverticulum, the most common congenital anomaly of gastrointestinal tract with a reported incidence of 2-3% at autopsy, represents a persistence of vitellointestinal (omphalomesenteric) duct and consists of a blind diverticular pouch. It measures approximately 5 cm and is situated on the ante-mesenteric border of the ileum. It is a true diverticulum and hence has all the layers of the gastrointestinal tract, unlike sigmoid diverticulae, which lacks smooth muscle layer. , The lifetime risk of complications in patients with a Meckel's diverticulum is usually small and occurs only in up to 4%.  Complications differ according to the age of the patient at the moment of the clinical presentation. In adult patients, intestinal obstruction is the most common complication (40%) and, in children, gastrointestinal hemorrhage is very common. Meckel's diverticulum may result in small bowel obstruction by a variety of mechanisms: By entangling a loop of small bowel around a fibrous cord or within a mesodiverticular band, intussusception, volvulus, incarceration within a hernia sac (Littre's hernia), chronic Meckel's diverticulitis, foreign body, or neoplasm. 
The term Bezoar comes from the Arabic "badzehr" or from the Persian "panzer," both meaning counter poison or antidote.  Causes of bezoar include the presence of indigestible material in the lumen, gastric dysmotility (including previous surgery like vagotomy and partial gastrectomy). Bezoars have been reported between the ages of 1 and 56 years, most presenting between the ages of 15-20 years and 90% in females. Approximately 10% show psychiatric abnormalities or mental retardation.  Bezoars mostly originate in the stomach, probably related to high-fat diet causing non-specific symptoms like epigastric pain, dyspepsia, and post-prandial fullness. They may also present with gastrointestinal bleeding (6%) and intestinal obstruction or perforation (10%). Rarely, the bezoars may extend into the small intestine as a tail (Rapunzel syndrome) or may get broken lodging in the intestine to cause intestinal obstruction, ulceration, bleeding, and perforation. Small intestinal bezoars per se are rare and have been reported after truncal vagotomy. 
Bowel obstruction due to a phytobezoar in a Meckel's diverticulum is rare and very less number of cases have been reported in literature. ,
The clinical assessment on its own might not be enough to get a correct diagnosis. About 50-70% of small bowel obstructions by bezoars are diagnosed by abdominal radiography by showing dilated bowel loops, air-fluid levels, and thickened bowel wall. Barium enema could be helpful in non-obstructive bezoar's case; the obstruction's shown like an intraluminal-filling defect. Barium enema could sometimes show a mottled appearance similar to villous tumor. On ultrasound examination, bezoars appear as an intraluminal mass with an hyperechoic arc like surface and a marked posterior acoustic shadow appears. Computed tomography (CT) scan, demonstrating dilated small bowel loop and well-defined round, heterogeneous intraluminal mass in distal segment, is completely diagnostic. The mass could be outlined by the bowel wall and present characteristic internal gas bubbles. CT scan is useful to localize the bezoar as well as to identify complications like perforation and obstruction. 
The treatment of phytobezoar could be either medical or surgical. The medical approach consists of administration of large amount of oral fluid in association with antispasmodic agents in case of little bezoar with no signs of obstruction. Other non-surgical treatments could be performed through endoscopic electrosurgical knife or extracorporeal lithotripsy, both to fragment bezoars. All these procedures are often incomplete and expose to iatrogenic complications such as oesophageal-gastric injuries (perforation-bleeding tear-hematoma) or intestinal obstruction due to distal migration of daughter fragments. Surgical treatment of bezoar is performed by removing the same during gastrotomy and/or enterotomy. ,,
Our patient underwent explorative laparotomy that confirmed the obstruction due to distended terminal ileum at the region of Meckel's diverticulum due to phytobezoar, ending up with small bowel obstruction. This patient was an operative surprise since the patient did not give any contributory history and the presentation was essentially as a case of acute intestinal obstruction.
| Conclusion|| |
Meckel's diverticulum complications are relatively rare, presenting in only 4% of patients. Small bowel obstruction is, after bleeding, one of the most frequent presentations of symptomatic Meckel's diverticulum in adults, causing a volvulus or by rolling up a loop of small bowel around a fibrous cord. The acute small bowel obstruction at the region of Meckel's diverticulum lumen caused by a foreign body, as phytobezoar, is unusual. The preoperative diagnosis of phytobezoar at the region of Meckel's diverticulum as a cause of small bowel obstruction is difficult with CT playing a role in identifying this condition, but the real etiological factor and the diverticulum's involvement in the obstruction can be correctly identified only intraoperatively as a unexpected surprise, as shown in the reported clinical case.
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[Figure 1], [Figure 2], [Figure 3]