CASE REPORT Hellenic Journal of Surgery (2019) 91:1, 44-48

Small Bowel Obstruction Due to Phytobezoars:

Report of Four Cases and Literature Review
Paschos KA, Triantaphilidis A, Chatzipourganis K, Paraskeva Aikaterini, Gravalidou Ioanna, Chatzigeorgiadis A

Abstract
Bezoars are concretions of indigestible foreign materials that develop within the gastrointestinal (GI) tract. A variety
of materials received orally may form these masses. According to their composition, bezoars are classified as phyto-
bezoars, which are the most frequent, trichobezoars, pharmacobezoars, lactobezoars, and other more rare entities.
They are formed most frequently in the stomach and they may trigger serious symptoms, including dysphagia, ab-
dominal pain, hematemesis, and intestinal obstruction or perforation. Contrast-enhanced computerized tomography
(CT), in conjunction with GI endoscopy, has contributed substantially to the prompt and accurate diagnosis of these
masses. Endoscopy also offers reliable therapeutic options, either through chemical disintegration of the bezoars or
mechanical fragmentation and removal. The more serious cases of intestinal bezoars are usually treated surgically,
either laparoscopically or via traditional laparotomy. This series describes four cases of intestinal phytobezoars that
caused small bowel obstruction, and, in one case perforation, and were all treated surgically. Current advances in
the diagnosis and treatment of bezoars are discussed and compared with the well-established methods.

Key words: Bezoar; ileus; intestinal obstruction; phytobezoar; small intestine; stomach

Bezoars are constituted of large conglomerates of poorly- motility and decreases acidity within the stomach, lead-
or non-digested material, formed within the gastrointestinal ing to bezoar formation and transfer to the small bowel.
(GI) tract. They are named according to their composition, This abnormal process may give rise to symptoms and/or
for example phytobezoar, from the Greek word phyto conditions such as ileus and acute abdomen [5,4]. Other
(φυτό)=plant, which are composed of vegetable and/or predisposing factors for phytobezoar formation may be
fruit matter, such as celery, prune, grape skin, orange, mastication abnormalities, excessive high-fiber food con-
persimmon, etc., and are the most common. Other types sumption, long-term antacid treatment, diabetic neuropathy,
are trichobezoars, from the Greek word tricha (τρίχα)=hair hypothyroidism and myotonic dystrophy. Primary intestinal
which contain hair, lactobezoars, which are formed from bezoars are extremely rare and are usually associated with
concentrated infant milk formula, pharmacobezoars, from intestinal tumors, diverticula or strictures, disorders that
the Greek pharmaco (φάρμακο)=medication, from medica- cause or facilitate the entrapment of food material in the
tions including kayexalate, antacids, cholestyramine, etc., small bowel [6,5].
and other less frequent entities such as paperbezoars [1-3]. This case series presents the recent experience of a
The stomach is the most common site of bezoar formation. regional Greek hospital regarding the diagnosis and treat-
The clinical manifestations range from no symptoms at all ment of small bowel obstruction caused by phytobezoars.
to acute abdomen, depending on the location of the bezoar.
Small bowel obstruction secondary to bezoars is rare, ac-
counting for 0.4-4.8% of all causes of obstruction [4]. Presentation of cases
The association between gastrectomy and phytobezoar Case 1
formation is widely accepted. While the pylorus of a normal A 68-year-old male presented at the emergency depart-
stomach impedes the passage of vegetable and fruit fibers ment (ED) with severe diffuse abdominal pain of sudden
before they are hydrolyzed, gastric surgery disturbs gastric onset, nausea and vomiting. His medical history included
partial gastrectomy for benign gastric ulcer 4 decades
Department of Surgery, Drama General Hospital, Drama, Greece earlier. On physical examination the patient had increased
Corresponding author: Paschos A Konstantinos MD, MSc, PhD bowel sounds and abdominal discomfort, mainly epiga-
Consultant Surgeon, Department of General Surgery, General Hospital stric, without tenderness. No palpable mass or blood was
of Drama, Terma Ippokratous St., 66100, Drama, Greece detected on rectal examination. His blood pressure was
Tel: +30-2521-350413, e-mail: kostaspaschos@yahoo.gr
140/85mmHg, his pulse rate was 87/minute and he was
Received Feb 25, 2019; Accepted Mar 12, 2019 afebrile. Initial laboratory data showed mild neutrophilic

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 Small Bowel Obstruction Due to Phytobezoars 45

leukocytosis; white blood cell count (WBC) 12.52k/μl, neu- tion, with end-to-end anastomosis. The postoperative
trophils 76.2%, hemoglobin (Hb) 13.8g/dl and urea 47mg/ course was uneventful and the patient was discharged
dl. An abdominal X-ray was consistent with gas ileus and home the 11th day.
a nasogastric tube was inserted.
Although his clinical status showed temporary im- Case 3
provement, the intestinal distention recurred 3 days later. A 51-year-old man attended the ED with a two-day
Abdominal helical computed tomography (CT) revealed history of epigastric pain and vomiting. His medical history
dilated jejunal and ileal loops up to the ileocecal valve and included partial gastrectomy because of a benign gastroduo-
a heterogeneous mass with a honeycomb configuration denal ulcer 3 decades earlier, appendicectomy and HBSAg
containing pockets of air in the terminal ileum (Figure 1A). positive for Hepatitis B. On physical examination he had
Laparotomy revealed a phytobezoar (15x5cm), 30-40 cm temperature 37.2 C°, blood pressure 140/80 mmHg and
proximal to the ileocecal valve, which was removed via pulse 100/min. His blood tests were within the normal range
enterotomy (Figure 1B). The patient had an uneventful (WBC 8.18k/μl, neutrophils 78.9%, Hb 14.2g/dl), and liver
recovery and was discharged on the 7th postoperative day and renal biochemistry unremarkable. Abdominal helical
with counseling on dietary habits and proper mastication CT scan showed a heterogeneous mass in the terminal ileum
to avoid similar problems in the future. with intestinal distention proximal to the mass.
Exploratory laparotomy revealed a phytobezoar (8x3cm)
Case 2 that was removed through an enterotomy. The patient reco-
A 72-year-old female was brought to the ED with vered well and was discharged on the 6th postoperative day.
abdominal pain, severe constipation and no flatus dis-
charge. Her medical history included an abdominop- Case 4
erineal resection 4 years earlier, with a postoperative A 62-year-old man was admitted to the surgical depart-
midline hernia. Physical examination identified diffuse ment, presenting with repetitive vomiting for 2 days, diffuse
abdominal sensitivity on deep palpitation, and diminished abdominal pain and distention. He was a heavy drinker,
bowel movements on abdominal auscultation. Her blood and had a history of surgical vagotomy and pyloroplasty
pressure was 155/85mmHg and her pulse 65/minute. Her for gastric perforation 40 years earlier. In addition, he had
blood tests were unremarkable, apart from anemia, with surgery for ileus due to intestinal phytobezoar 20 years ago.
Hb 10.3g/dl. Abdominal helical CT demonstrated small He also had a coronary by-pass operation in the recent past
bowel obstruction with perforation and the presence of a and was taking acetylsalicylic acid (100mg/day). Physical
large intraluminal mass with a honeycomb pattern, con- examination revealed a tender distended abdomen, sensitive
taining pockets of air (Figure 2A). Following resuscitation, to deep palpitation and an empty rectum. An abdominal
exploratory laparotomy was performed which revealed a X-ray showed distended intestinal loops with gas, and a
terminal ileum perforation, along with a large phytobezoar nasogastric tube was therefore inserted. Helical CT scan
(75x8cm) (Figure 2B). The phytobezoar was removed and revealed intestinal ileus and a mass in the ileum with a
intestinal resection was performed at the site of perfora- mottled air pattern (Figure 3). Exploratory laparotomy

1A 1B
Figure 1. A. Contrast-enhanced computerized tomography (CT) showing a phytobezoar (white arrow shows typical mottled appearance) in the
ileum causing intestinal obstruction; B. Intraoperative image of enterotomy performed via laparotomy to remove the ileal phytobezoar (15x5cm).

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46 Paschos KA, et al

2A 2B
Figure 2. Intestinal phytobezoar with perforation in a 72-year-old female: A. Contrast-enhanced computerized tomography (CT) showing
the phytobezoar. B. Intraoperative image showing the phytobezoar (75x8cm).

revealed multiple intestinal symphyses attributed to the

previous abdominal operations, and a phytobezoar in the
ileum (11cmx4cm), which was removed through an ileal
enterotomy.
Postoperatively the patient developed a superficial surgi-
cal site infection and was discharged from the hospital on
the 15th day after surgery.

Discussion
The word bezoar originates either from the Arabic term
“badzehr” or possibly the Persian word “padzahr”, both
meaning to expel poison, or counterpoison or antidote.
These words were used to describe a greenish, hard con-
Figure 3. Intestinal phytobezoar in a 62-year-old male: Contrast-
cretion found in the animal stomach, which was formerly enhanced computerized tomography (CT) showing the phytobezoar
considered a useful medication, sometimes with magical (11x4cm) in the ileum causing intestinal obstruction (white arrow
properties. In the mid-1890s, Quain, an Irish surgeon shows typical mottled appearance).
and anatomist at the university of London, reported a
mass in the stomach, found on autopsy, which he called
a “bezoar” [7,5]. surgically. Among them forteen cases were attributed to
Bezoars are recognized as infrequent entities with phy- phytobezoars (3.2%) [11].
tobezoars being the most common type. In 1987, Ahn and Gastric surgery (vagotomy, pyloroplasty, antrectomy,
colleagues reported 14 cases of bezoar in 3,247 esophago- gastrojejunostomy) is a main predisposing factor for bezoar
duodenoscopies (0.43%) performed in a 7-year period [8]. formation, and had been performed in 3 of our 4 cases. In
More recently, Mihai and colleagues reported 34 cases of the published series, 20-93% of patients who presented
phytobezoar of 49 bezoars found over 20 years, with a lower bezoars had undergone some type of gastric surgery. It has
overall incidence (0.068%) [9]. been reported that 5-12% of patients who had undergone
Although bezoars are developed primarily in the sto- gastric surgery subsequently formed one or more bezoars
mach, they may migrate into the small bowel and cause in their GI tract [12,4].
acute or incomplete obstruction. Kirstein and colleagues The clinical presentation of bezoars varies. They may
reported a series of 65 patients in 6 years who were operated develop and remain asymptomatic or cause only transient
on laparoscopically for intestinal obstruction. Among them subacute symptoms, or they may give rise to multiple
three cases caused by bezoars (4.6%) represented the fifth abnormal symptoms and signs originating from the ali-
causative factor [10]. Concurrently, Yakan and colleagues mentary tract. Typically, they present with abdominal pain
reported a series of 432 patients in 10 years who were treated or discomfort, anorexia and nausea [13]. Bezoars can in-

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 Small Bowel Obstruction Due to Phytobezoars 47

crease the intraluminal pressure, they may cause ulcers as In the event that the aforementioned approaches are
well as mucosal necrosis. More rarely, bezoars may cause unsuccessful, or when the bezoars are located in the small
complete intestinal obstruction or perforation, which are intestine or cause ileus, intestinal ischemia or perforation,
associated with serious symptoms, including severe pain, surgical intervention is mandatory. Bezoars that cause
abdominal rigidity, hypotension, mental disorientation obstruction are usually located in the distal part of the
and shock [14,15]. small bowel, less than 90cm proximal to the ileocecal
Recent advances in imaging methods have facilitated valve, due to the lower motility of this intestinal segment,
the diagnosis of bezoars and the complications that they its smaller diameter, and the increased water absorption
may trigger. Upper GI bezoars can be localized with the use that occurs at the distal end of the ileum. When surgi-
of esophago-gastroduodenoscopy, and this technique may cal treatment is chosen, two different approaches are
also offer therapeutic options. Usually, a bezoar appears available, laparoscopic abdominal exploration or lapa-
as a single mass in the stomach and the color may vary, rotomy. Both approaches allow enterotomy and removal
depending on their composition and chemical synthesis of the mass [28-30]. The “milking” technique, to move
(black, green, blue). Very rarely, they may be multiple or the bezoar proximally towards the stomach or distally
may become impacted in the esophagus or duodenum [1]. through the ileocecal valve, has been described in the
In the case that they are localized in the ileum, which case of laparotomy, although with many objections, as
may cause ileus, radiological imaging plays a critical role in these maneuvers may cause laceration of the intestinal
the diagnostic process. Plain X-ray may show air-fluid levels, serosa or mesentery and intraluminal bleeding [31,11].
indicating intestinal obstruction, but not differentiating its Although open laparotomy is well established for bezoar
cause. Ultrasonography (U/S) can detect bezoar-induced ileus treatment, laparoscopic surgery is being used increasingly
(sensitivity 88%-93%), as these masses create hyperechoic over the last decade, mostly performed in appropriately
acoustic shading, but U/S is an operator-dependent diagnostic equipped and well-staffed medical centers [32,33]. Fur-
technique, and abdominal distention with multiple air-fluid ther research is needed to clarify the etiology and chemical
levels may block the view of the bezoar on U/S [16,17]. synthesis of bezoars. Taking into consideration the human
Barium studies may show the localization of bezoars aging that is occurring globally, mainly in the developed
and can differentiate diverticular disease, intraluminal countries, bezoars are being detected increasingly com-
adenomas and malignancies from bezoars, but are not monly. Past gastric surgery, medications, peptic abnormali-
indicated in emergency investigations and may exacerbate ties and mastication problems that affect older people act
peritonitis in the presence of intestinal perforation [16]. synergistically in bezoar formation. Modern endoscopy
It is generally accepted that contrast-enhanced CT is the offers reliable diagnostic and therapeutic options, contrast-
preferred imaging method for the diagnosis of bezoars, enhanced CT constitutes a reliable diagnostic technique,
with sensitivity of up to 90% and specificity of up to 60%. and surgery continues to be the preferred treatment in
Regarding phytobezoars, CT presents round or oviform complicated cases.
masses with air bubbles and a honeycomb configuration.
Conflict of Interest: The authors declare that they have no
A round, mottled intraluminal mass (similar to feces in
conflict of interest
appearance) in the area of obstruction, with dilated intes-
tinal loops proximally and collapsed intestine distally is a
pathognomonic CT sign for bezoar-induced ileus [18-20].
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