Clinical diagnosis
Case 171
【Progress】
After three times-abdomen CT, he eventually underwent surgical management. It revealed no findings of adhesive scar or strangulation but occlusive ileus. The small bowel was made an incision which showed a lump of konjac called in Japanese which is a kind of a gelatinous food. When he listened to the result, it became clear that he swallowed a lump of konjac without biting a few days ago because he lost all teeth.
【Discussion】
It is documented that gastrointestinal bezoars are categorized into phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars; phytobezoars arise from plant component; trichobezoars arise from eating hair and accumulate in groove of the stomach; pharmacobezoars arise from intake of soluble-difficult coating drugs; lactobezoars arise from synthetic milk feeding infants (1). Nowadays, improvement and innovation of the products lead to least come out the later two bezoars. Trichobezoars are often found in patients with mental disorder. In the recent clinical reality, phytobezoars are anticipated to experience although it is not so common.
In Japan, the dietary ileus can happen after swallowing persimmon, mushroom, konjac, mochi and peanut, indicating that all can become intestinal phytobezoars (3-7). Persimmon tannin is contained in the persimmon skin which is believed to polymerize and make a conglomerate with cellulose and proteins with gastric acids.
Abdomen CT is crucial to diagnose whether ileus or not. Using CT, it is important to judge whether the ileus is life threatening or not. The key is to find out the occlusive transposition site, if possible. The diagnosis of dietary ileus is sometimes difficult because adhesive ileus, strangulation ileus, internal hernia, tumor-bearing obstructing ileus and non-occlusive mesentery ischemia are more encountered. The dietary ileus is reported to occur in 1-3% of cases with small bowel obstruction (1-3).
Of all phytobezoars causing ileus, mochi can be demonstrated in high density using CT because CT values of mochi reach 100 HU or greater. Meanwhile, peanut can be demonstrated in fat density because it contains lipid in 47% (8). In case of mushroom ileus, there is a case report that the occlusive mushroom contained fat component whose origin was unclarified. When the fat density is contained in the occlusive mass, the differentiation from invagination by lipoma or liposarcoma becomes problematic.
Persimmon, mushroom and konjac compose of water in 80% or greater. Especially, konjac contains water in 96% (9). They are visualized in water density on CT. In our case, the konjac lump responsible occlusive ileus cannot be identified probably because the konjac density is almost the same as intestinal fluid. Further, mesentery edema and ascites were demonstrated on abdomen CT (Fig. 1A). It is considered that the occlusive mass makes the small bowel dilated and its wall stretched, inducing the circulatory disorder, the ischemic change and the portal venous congestion. Eventually, dietary ileus can lead to the mesentery edema and ascites.
【Summary】
We present a seventy one-year-old male for nausea and vomiting. Abdominal findings indicated slight tenderness in the upper abdomen.
Three-times abdomen CT showed small bowel obstruction. The occlusive transition site was movable from right upper abdomen to lower abdomen via left upper abdomen. There was no mass visualized at the occlusive site on CT. Surgical management revealed a lump of konjac responsible to the occlusion. It is borne in mind that konjac composes of water in 96% which indicates the difficulty of differentiation from intestinal fluid. The dietary ileus is known to occur in 1 to 3 % of the small bowel obstruction. In our country, intestinal phytobezoars of persimmon, mushroom, konjac, mochi and peanut can be responsible to small bowel ileus. Of the phytobezoars on abdomen CT, mochi is visualized as a high density mass whereas peanut and mushroom can be as a lipid-bore mass. Meanwhile, persimmon and konjac can be as a water density mass.
【References】
1.Iwamuro M, et al. Review of the diagnosis and management of gastrointestinal bezoars. World J Gastrointest Endosc. 2015; 7(4): 336–345.
2.Yakan S, et al. A rare cause of acute abdomen: small bowel obstruction due to phytobezoar. Ulus Travma Acil Cerrahi Derg. 2010;16:459–463.
3.Ghosheh B, et al. Laparoscopic approach to acute small bowel obstruction: review of 1061 cases. Surg Endosc. 2007;21:1945–1949.
4.de Toledo AP, et al. Diospyrobezoar as a cause of small bowel obstruction. Case Rep Gastroenterol. 2012;6:596–603.
5.SHIGEMOTO N, et al. A CASE OF ILEUS DUE TO MUSHROOMS. Journal of Clinical Surgery. 66 (11), 2712-2715, 2005
6.Kohno S, et al. TWO CASES OF FOOD-INDUCED ILEUS DUE TO HEAVY INGESTION OF PEANUTS. Journal of Clinical Surgery. 57:853-856, 2002
7.Miller SF, et al. Acute intestinal obstruction caused by a peanutbezoar in a child. South Med J 74: 1554, 1981
8.9.cited by data and information supplied by google using the words of components of peanut or konjac.
2019.11.27