AJR 2000; 175:876-878
© American Roentgen Ray Society
Gastrointistinal Case of the Day |
Case 2
Small-Bowel Bezoar
Kenneth M. Vitellas,
Kuldeep Vaswani and
William F. Bennett
Small-bowel bezoars can arise in small-bowel diverticula, in a segment of
bowel associated with stricture formation, or proximal to small-bowel tumors
[1]. They almost always present
with obstruction and rarely with perforation
[1,
2]. If a small-bowel bezoar is
found, the stomach should be inspected closely. Concurrent gastric bezoar is
found in 17-21% of patients with small-bowel bezoar
[1,2,3,4].
CT reveals a well-defined ovoid intraluminal mass with a mottled gas
pattern in the dilated small bowel at the site of obstruction and an abruptly
collapsed lumen beyond the lesion. The mottled appearance is a result of air
bubbles retained in the interstices of the mass
[2,
4,
5]. The site of impaction is
usually the narrowest portion of the small bowel 50-75 cm from the ileocecal
valve or at the valve itself. Any part can be affected, especially in patients
with postoperative adhesions.
The abdominal radiograph (Fig.
2A) obtained at presentation with left abdominal pain shows a
large mottled gas and debris collection in left upper quadrant. The
contrast-enhanced CT scans (Figs.
2B,2C,2D)
show a large mass proximal to the jejunostomy site. The mass has multiple air
bubbles, fluid, and debris scattered throughout, giving it a mottled
appearance. Oral contrast material is noted surrounding the mass. The
abdominal radiograph (Fig. 2E) obtained 1 day after CT shows a large mottled gas collection with contrast
material. Axial CT scans (Figs.
2F,2G,2H)
obtained 5 months before presentation show focal dilatation of the jejunum
proximal to the jejunostomy.
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Fig. 2A. —45-year-old woman with 1-day history of left upper quadrant
abdominal pain. Abdominal radiograph obtained at presentation with left
abdominal pain shows large mottled gas and debris collection in left upper
quadrant (arrows).
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Fig. 2B. —45-year-old woman with 1-day history of left upper quadrant
abdominal pain. Contrast-enhanced CT scans show large mass proximal to
jejunostomy site (arrows). Mass has multiple air bubbles, fluid, and
debris scattered throughout, giving it a mottled appearance. Note oral
contrast material surrounding mass.
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Fig. 2C. —45-year-old woman with 1-day history of left upper quadrant
abdominal pain. Contrast-enhanced CT scans show large mass proximal to
jejunostomy site (arrows). Mass has multiple air bubbles, fluid, and
debris scattered throughout, giving it a mottled appearance. Note oral
contrast material surrounding mass.
|
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Fig. 2D. —45-year-old woman with 1-day history of left upper quadrant
abdominal pain. Contrast-enhanced CT scans show large mass proximal to
jejunostomy site (arrows). Mass has multiple air bubbles, fluid, and
debris scattered throughout, giving it a mottled appearance. Note oral
contrast material surrounding mass.
|
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Fig. 2F. —45-year-old woman with 1-day history of left upper quadrant
abdominal pain. Axial CT scans obtained 5 months before presentation show
focal dilatation of jejunum proximal to jejunostomy (arrows).
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Fig. 2G. —45-year-old woman with 1-day history of left upper quadrant
abdominal pain. Axial CT scans obtained 5 months before presentation show
focal dilatation of jejunum proximal to jejunostomy (arrows).
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Fig. 2H. —45-year-old woman with 1-day history of left upper quadrant
abdominal pain. Axial CT scans obtained 5 months before presentation show
focal dilatation of jejunum proximal to jejunostomy (arrows).
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This patient with prior small-bowel resection presented with left upper
quadrant abdominal pain. She was afebrile with a normal WBC. No signs of
peritonitis were noted on clinical examination. CT of the abdomen showed a
large mottled collection of predominately gas and debris with no air-fluid
level. Oral contrast material was noted to surround the mass, suggesting the
mass was intraluminal. No thick enhancing wall was identified to suggest an
abscess. In addition, the gas was noted to be diffusely scattered in the mass
and not in the wall of the bowel, excluding pneumatosis. The most likely
diagnosis of this case is small-bowel bezoar. Exploratory laparotomy showed an
intraluminal mass at the site of the previous jejunostomy. Pathology revealed
a phytobezoar of the small bowel with vegetable products in the small-bowel
lumen.
Bezoars of the gastrointestinal tract are most often found in the stomach
as persistent concretions of substances such as plant and vegetable fibers
(phytobezoar), persimmons (disopyrobezoar), or hair (trichobezoar)
[6]. Phytobezoars are the most
common and are characterized by concretions of poorly digested fibers, fruit
seeds, and pulpy fruits, especially oranges and persimmons. A primary
small-bowel bezoar without associated gastric bezoars is uncommon. Usually,
bezoar fragments from the stomach or bolus of food small enough to pass
through the pylorus will enter the small bowel where they absorb water,
increase in size, and become impacted
[6]. Complete mechanical
intestinal obstruction is the most frequent clinical presentation of bezoar.
Small-bowel obstruction caused by bezoar is rarely diagnosed
preoperatively.
Small-bowel pneumatosis—gas in the wall of the
intestine—usually occurs in the setting of bowel ischemia or infarction.
CT findings of pneumatosis are curvilinear, serpiginous, bubbly collections of
gas that occur circumferentially or in peripheral or dependent portions of the
bowel wall. Long segments of the bowel are usually involved.
Abscesses usually develop as a complication of intraabdominal inflammatory
processes or after laparotomy. Patients usually present with fever and
elevated WBC. On CT, abscesses appear as circumscribed round or oval soft
tissue-density masses with an attenuation of 10-30 H. If a well-formed capsule
is present, it often shows contrast enhancement, whereas the central area of
the abscess, which contains necrotic material, does not. Intracavitary gas is
a suggestive finding in 40-50% of abscesses. The gas may be distributed as
finely dispersed air bubbles throughout the collection or as an air-fluid
level.
Small-bowel feces is a sign reported in patients with severe stasis of
fecal content in a dilated small bowel, usually in patients with cystic
fibrosis or high-grade small-bowel obstruction. Small-bowel feces is more
amorphous and affects longer segments.
References
-
Lo CY, Lau PWK. Small bowel phytobezoars: an uncommon cause of
small bowel obstruction. Aust N Z J Surg
1994;64:187
-189[Medline]
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Licht M, Gold BM, Katz DS. Obstructing small-bowel bezoar:
diagnosis using CT. AJR 1999;173
: 500-501[Free Full Text]
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Ko YT, Lim JH, Lee DH, Yoon Y. Small intestinal phytobezoars:
sonographic detection. Abdom Imaging
1993;18:271
-273[Medline]
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Quiroga S, Alvarez-Castells A, Sebastia MC, Pallisa E, Barluenga E.
Small bowel obstruction secondary to bezoar: CT diagnosis. Abdom
Imaging 1997;22:315
-317[Medline]
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Ko SF, Lee TY, Ng SH. Small bowel obstruction due to phytobezoar:
CT diagnosis. Abdom Imaging
1997;22:471
-473[Medline]
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Robles R, Parrilla P, Escamilla C, et al. Gastrointestinal bezoars.
Br J Surg
1994;81:1000
-1001[Medline]
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