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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 33  |  Issue : 1  |  Page : 59-61

Wire bezoar - Unique presentation with duedenojejunal flexure perforation


1 Department of Surgery, Down Town Hospital, Dispur, Guwahati, Assam, India
2 Sr. Consultant Paediatric Surgery Division, Department of Surgery, Down Town Hospital, Dispur, Guwahati, Assam, India

Date of Web Publication14-Oct-2019

Correspondence Address:
Toijam Soni Lyngdoh
Department of Surgery, Down Town Hospital, Dispur, Guwahati - 781 006, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_39_18

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  Abstract 


Bezoars are commonly found in the stomach, which are usually trichobezoar or phytobezoar. Signs and symptoms depend on the location and type of bezoars. Small intestinal perforation following wire bezoar has not been reported earlier. We report a 26-year-old schizophrenic male presented to us with features of perforation peritonitis. Preoperative abdominal radiograph was suggestive of unexpected intraoperative findings. Celiotomy with gastrostomy, feeding jejunostomy, and primary closure of perforation over a large bore T-tube was done. The patient was discharged after prolonged hospitalization. Wire bezoar presenting with jejunal perforation has not been reported earlier although every high possibility of perforation exists when the wires are pointed and long, where negotiation at the duodenojejunal flexure may be difficult.

Keywords: Jejunal perforation, schizophrenia, wire bezoar


How to cite this article:
Roy AK, Lyngdoh TS. Wire bezoar - Unique presentation with duedenojejunal flexure perforation. J Med Soc 2019;33:59-61

How to cite this URL:
Roy AK, Lyngdoh TS. Wire bezoar - Unique presentation with duedenojejunal flexure perforation. J Med Soc [serial online] 2019 [cited 2019 Nov 12];33:59-61. Available from: http://www.jmedsoc.org/text.asp?2019/33/1/59/269109




  Introduction Top


Bezoars are conglomeration of retained animal, vegetable, or indigestible foreign bodies in the gastrointestinal (GI) tract. The signs and symptoms depend on the nature of the ingested material.[1] Bezoars most commonly present with features of intestinal obstruction or malabsorption. Presentation with perforation in itself is very rare.[2] The diagnosis can be confirmed from the history supplemented by various investigative modalities, especially abdominal radiographs and ultrasound. Treatment options include conservative with dietary therapy or enzymatic agents which only works for certain bezoars but not for wires, which are metallic substances covered with rubber or plastic coatings. In such cases as in our index case, the only option is surgical.[3]


  Case Report Top


A 26-year-old schizophrenic male presented to our surgical emergency with a history of pain abdomen, gradually progressive abdominal distension, and multiple episodes of bilious vomiting of 24-h duration. There was associated history of ingestion of foreign bodies such as small glass bottles and loose soil in the past. Physical examination revealed blood pressure of 90/72 mmHg and pulse rate of 140/min. Abdominal examination revealed tenderness, guarding, and board-like rigidity with absent bowel sound. Routine hemogram showed hemoglobin of 9.6 gm% with total leukocyte count of 14,500/mm3 with a shift to the left and normal serum electrolytes. Diagnostic chest and abdominal radiograph revealed air under the right hemidiaphragm along with faint shadows of multiple long and curved radiopaque foreign bodies lying in the region of duodenum conforming to its luminal curvature [Figure 1]. The patient was taken up for emergency celiotomy after adequate resuscitation. Operative findings include eight numbers of approximately 13-cm long rubber-coated wires, few of which were seen extruding from the perforation site at the duodenojejunal flexure [Figure 2] and [Figure 3]. All the wires were retrieved through the perforation site after milking and manipulating from the duodenum distally and absence of residual foreign body were ensured by palpation of the stomach, duodenum, jejunum, and ileum. Stamn's gastrostomy, Whitzel's feeding jejunostomy, and closure of the jejunal perforation over a 16 Fr T-tube were done with a drain in the left paracolic gutter which continued to drain light bilious fluid for 3 weeks suggestive of leak from the perforation site, which finally healed and the drain removed. The patient was eventually discharged on the 31st postoperative day with advice to continue jejunostomy feed and psychiatric evaluation. Barium meal and follow through on follow-up revealed no leak and gastrostomy, jejunostomy, and T-tubes were removed one after another over a period of few days.
Figure 1: Multiple faint shadows in the region of the duodenum

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Figure 2: An intraoperative picture of the perforation site

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Figure 3: Extracted wires

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  Discussion Top


The term bezoar is derived from the Arabic word “badzehr” or the Persian “panzer” meaning counter poison or antidote.[4] The presence of metallic bezoar has been reported earlier but not wires.[5] They occur mainly in the young mentally unsound persons.[6]

Gastrointestinal bezoars can be easily diagnosed in most patients. Plain X-rays, like in our patient, are unique and lead to the diagnosis. However, diagnostic difficulties arise in patients with radiolucent bezoars in which contrast studies of the GI tract and computed tomography scan or upper GI endoscopy are often necessary. Plain X-ray of the abdomen suggested the diagnosis in our patient. Occasionally, bezoars are found incidentally when an emergency laparotomy is done secondarily to bowel obstruction. Perforation occurs when the wire failed to negotiate the duodenojejunal flexure or because of the pressure necrosis of the intestinal wall due to prolonged presence.

Several treatment options have been proposed for bezoars depending on the clinical presentation as well as on the composition of the bezoar. Chemical and enzymatic compounds have been used for dissolution of phytobezoars and lactobezoars.[7] Endoscopic removal of small bezoars is also advocated; however, once perforation or intestinal obstruction occurs, laparotomy is mandatory. Frequently, synchronous bezoars are found in the stomach or other areas of the GI tract; therefore, it is mandatory to carry out a thorough exploration of the small intestine and colon.[8] After discharge, recurrence has been reported in up to 14% of cases, especially in patients with psychiatric disturbances.[9] Therefore, psychiatric evaluation and therapy are needed to prevent a recurrence. This case is being reported because of its rarity and uniqueness in presentation.


  Conclusion Top


Although bezoar with its complications is a common entity wire, bezoar with perforation is very rare. Diagnosis is comparatively easy with the majority being psychotic and treatment if perforated is always surgical exploration. Psychiatric evaluation is necessary to follow-up.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Acar T, Tuncal S, Aydin R. An unusual cause of gastrointestinal obstruction: Bezoar. N Z Med J 2003;116:1173.  Back to cited text no. 1
    
2.
Andrus CH, Ponsky JL. Bezoars: Classification, pathophysiology and treatment. Am J Gastroenterol 1988;83:476-78.  Back to cited text no. 2
    
3.
Campos RR, Paricio PP, Albasini JLA. Gastrointestinal bezoars. Presentation of 60 cases. Dig Surg 1990;7:39-44.  Back to cited text no. 3
    
4.
Ibuowo A, Saad A, Okonkwo T. Giant gastric trichobezoar in a young female. Int J Surg 2008;6:e4-6.  Back to cited text no. 4
    
5.
5 Kaplan R, Celebi F, Guzey D, Celik AS, Erozgen F, Firat N. Medical image. Metal bezoar. N Z Med J 2005;118:1588.  Back to cited text no. 5
    
6.
Ersoy YE, Ayan F, Ersan Y, et al. Gastro-intestinal bezoars: Thirty-five years experience. Acta Chir Belg 2009;109:198-203.  Back to cited text no. 6
    
7.
Ladas SD, Triantafyllou K, Tzathas C, et al. Gastric phytobezoars may be treated by nasogastric Coca-Cola lavage. Eur J Gastroenterol Hepatol 2002;14:801-3.  Back to cited text no. 7
    
8.
Kumar GS, Amar V, Ramesh B, et al. Bizarre metal bezoar: A case report. Indian J Surg 2013;75:356-8.  Back to cited text no. 8
    
9.
Robles R, Parrilla P, Escamilla C, et al. Gastrointestinal bezoars. Br J Surg 1994;81:1000-1.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
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Case Report
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