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79-year old patient with a medical history of type 2 diabetes, hypertension and occasional alcohol consumption that suffered a multiple organ failure of unknown cause developing ischemic colitis and bacteremia. He had a second episode of ischemic colitis complicated with ileal perforation that required right hemicolectomy and ileo-transverse anastomosis 7 months prior to this event.
Patient presented with a month history of insidious abdominal pain and distension, associated with intermittent constipation. No nausea or vomiting was reported. During his stay in the emergency room he had diarrheic stools and abdominal X-rays showed dilated loops of bowel and air-fluid levels. He was then admitted with the diagnosis of intestinal sub-occlusion.
Conservative treatment was started with a fasting diet and a nasogastric tube. Because of the lack of improvement after 48 hours an abdominal CT scan was ordered. It reported a bezoar (FIG 1) in the distal ileum formed by 30-40 nodular hyper dense images conditioning proximal dilatation of the small bowel (FIG 2).
A diagnostic laparotomy revealed dilated small bowel loops leading to a stenotic ileo-transverse anastomosis. Multiple fruit pits were found causing an obstruction at that level. The previous stenotic anastomosis was resected and a new mechanic laterolateral ileocolic anastomosis was build using the Barcelona technique.
The patient had a favorable postoperative course with little pain and discomfort. He was put on total parenteral nutrition and oral diet was reintroduced after four days with no nausea or vomiting. Patient was discharged a week after surgery. Pathological findings were compatible with phytobezoar.
One month after surgery he was completely asymptomatic.
FIG 1. Stenotic ileo-transverse anastomosis.
FIG 2. Cherry pit bezoar causing ileal sub-occlusion.