A RARE CAUSE OF INTESTINAL OBSTRUCTION Dr.ALAA A.K. MOHAMMED CONSULTANT SURGEON. CABS,FRCS, FMAS,WALS MEMBER,SAGES MEMBER.

2 CASES PRESENTED BOTH PRESENTED IN THE SAME PERIOD NOVEMBER 2008. THE ONLY 2 CASES I HAD SEEN IN MY SURGICAL CAREER,FOLLOWING THE ROLE THAT PATIENTS COMING IN THREES OR GROUPS. BOTH HB POSITIVE???????

CASE NO.1 68-YEAR AGE MALE PATIENT WITH RECURRENT ABDOMINAL PAIN OF FEW DAYS DURATION. LAST FEW HOURS THE PAIN MORE SEVER WITH VOMITING ,CONSTIPATION . PAST HISTORY:RELEVANT HISTORY OF EXPLORATIVE LAPAROTOMY ON NOV. 1999 FOR GALL STONE ILEUS ,AS A RESULT OF CHOLECYST- DUODENAL FISTULA WITH STONE MIGRATION DOWN TO THE BOWEL BLOCKING IT AT THE TERMINAL ILEUM SITE.

DIFFERENTIAL DIAGNOSIS INTESTINAL OBSTRUCTION-------------------------- -RECURRENT GALL STONE ILUES. -ADHESIONS.

PLAIN X-RAY ABDOMEN

CONSERVATIVE MEASURES -- NOTHING BY MOUTH. ---IV FLUID . ---CLOSE OBSERVATIVE . CT SCAN DONE,SHOWING FEATURES OF INTESTINAL OBSTUCTION.INTRALUMINAL STONES SEEN.

CT SCAN ABDOMEN

CT SCAN

CT SCAN REPORT

NO,IMPROVEMENT 24 HOURS AFTER CONSERVATIVE MEASURE

PREPARATION FIRST SCAR OF THE OLD SURGERY

EXPLORATIVE LAPAROTOMY

PHYTOBEZOAR -SMALL BOWEL

ENTEROTOMY CLOSURE

PHYTOBEZOAR-GASTRIC

GASTRIC CLOSURE

PHYTOBEZOAR AFTER REMOVAL

SMOOTH POST OPERATIVE RECOVERY LATER DISCHARGED HOME. FEW DAYS

CASE NO.2 A 55-YEAR AGE MALE PATIENT WITH RECENT ATTACK S OF ABDOMINAL PAIN i.e. LAST 2-3 DAYS,WITH VOMITING AND CONSTIPATION. PAST HISTORT:HISTORY OF PEPTIC ULCER SURGERY MANY YEARS AGO. PROVISIONAL DIAGNOSIS: INTESTINAL OBSTRUCTION—ADHESIONS.

PLAIN X-RAY ABDOMEN

CONSERVATIVE TREATMENT NO,IMPROVEMENT

EXPLORATIVE LAPAROSCOPY-ADHESIOLYSIS

PER-LAPAROSCOPY BULGE NOTICED –EXPLORATIVE LAPAROTOMY PERFORMED

ENTEROTOMY-SMALL BOWEL PHYTOBEZOAR

GASTRIC PHYTOBEZOAR

AFTER REMOVAL

WHAT IS PHYTOBEZOAR? Phytobezoars are concretion of poorly digested fruit and vegetable fibres that are found in the alimentary tract, particularly orange pith or pulp in patients with (فاكهة الكاكيhistory of surgery and persimmon(in patients without previous surgery []. Persimmon contains a high concentration of tannin, a monomer that polymerise in the presence of gastric acid and the polymerized tannin then acts as a nucleus for bezoar formation.

TYPES OF BEZOAR phytobezoars :which are concretions of vegetable matter . Trichobezoars: are gastric concretions of hair fibres present usually in patients of psychiatric predisposition. Pharmacobezoars: medication bezoars; when taken in bulk, various substances such as antacids, cavafate or cholestyramine . Lactobezoar: seen during the first week of life (5) in low birth weight neonates who are fed on concentrated milk formula.

TRICHOBEZOAR

CAUSATIVE FACTORS Previous gastric resection or ulcer surgery such as partial gastrectomy or truncal vagotomy with pyloroplasty predisposes to bezoar. Other predisposing factors are ingestion of high fibre foods, abnormal mastication, diminished gastric secretion and motility, autonomic neuropathy in diabetic patients and myotonic dystrophy []. Bezoars are currently regarded as a sequel of gastric surgery and are included in the postgastrectomy syndromes. Incidence of post gastrectomy bezoar range between 5-12% []. In a normal stomach, vegetable fibres which cannot pass through the pylorus undergo hydrolysis within the stomach, which softens them enough to go through the small bowel. After gastric surgery, the gastric motility is disturbed and the gastric acidity is decreased, and the stomach may empty rapidly with an increased possibility of bezoar formation.

CONT, CAUSATIVE FACTORS Normally found in the stomach, they may pass into the small bowel. Primary small bowel bezoar is very rare and is normally formed in patients with underlying small bowel disease such as diverticulum, stricture or tumour. Phytobezoar can also develop secondarily if there are areas of sufficient stagnation within a dilated bowel segment as may occur in patients with strictures caused by Crohn’s disease, TB or previous surgery, or in patients with small bowel diverticula. In such cases, the bile constituents or calcium salts contribute to bezoar development .[

BEZOAR INTESTINAL OBSTRUCTION Small-bowel obstruction accounts for about 20% of hospital admissions (7) . Common causes are adhesions, strangulated hernias, malignancy, volvulus and inflammatory bowel diseases. Phytobezoars are rare, accounting for only 0.3-6% of all intestinal obstructions .To diagnose such cases need high degree of suspicion. PLAIN X-RAY ABDOMEN:NON-SPECIFIC INTESTINAL OBSTRUCTION.

DIAGNOSIS -HIGH DEGREE OF SUSPICION. -PLAIN X-RAY ABDOMEN.NON-SPECIFIC. -US IF A MASS FELT. -GI+ CONTRAST STUDY. -CT SCAN.

GI STUDY WITH CONTRAST

CT SCAN IS BELIEVED TO BE PATHOGNOMONIC

the presence of a round or ovoid intraluminal mass with a ‘mottled gas’ pattern

CT SCAN-MASS WITH MOTTLED GAS PATTERN

TREATMENT OPTIONS ---ENDOSCOPY—GASTROSCOPY-FOR GASTRIC. ---LAPAROTOMY/LAPAROSCOPY-FOR INTESTINAL. ((THANK YOU VERY MUCH

SYRIA IRAQ