A case of small bowel obstruction due to phytobezoars
A 63-year-old Syrian male presented to the emergency department with a 2-day history of generalized colicky abdominal pain associated with repeated vomiting and absolute constipation. There was no associated history of alteration of bowel habit, rectal bleeding, fever or dysuria.\nHis past medical history was significant for a laparotomy in 1979 due to a peptic ulcer-related complication, but he was unaware of the details. He was also recently diagnosed with diabetes mellitus for which he was using herbal treatment consisting of boiled olive tree leaves (Olea europaea).\nOn physical examination, the patient looked unwell but was hemodynamically stable and apyrexial. His abdomen was distended. There was a midline laparotomy scar with a reducible incisional hernia in the epigastric area. He had mild lower abdominal tenderness with no muscle guarding and his bowel sounds were exaggerated. Rectal examination revealed no abnormalities and there was a small amount of stool in the rectum.\nThe rest of the physical examination was unremarkable. Routine blood investigation and abdominal X-rays were obtained. Apart from leukocytosis, they were unremarkable.\nA contrast-enhanced CT scan was arranged and it showed features of SBO with collapse of the terminal ileum. There was evidence of a previous gastrojejunostomy with suspected foreign bodies in the stomach and proximal ileum. (Figs and )\n.\nAt laparotomy, a previous gastrojejunostomy with dense adhesions in the upper abdomen was found. An obstructing hard foreign body was palpable in the ileum with dilatation of the proximal small bowel loops. A larger similar foreign body was mobile and palpable within the stomach. (Fig. ) Both foreign bodies were removed through an enterotomy and gastrotomy, respectively, and the bowel was decompressed. After limited adhesiolysis, the abdomen was closed en mass repairing the midline hernia defect.\nPostoperative recovery was unremarkable except for a short duration of ileus, after which the patient made a steady recovery. He was referred to the diabetology department and dietician during admission and was discharged with outpatient clinic follow-up.\nA follow-up upper GI endoscopy was done and it showed evidence of a hiatus hernia with gastrooesophageal reflux disease. The patient was well controlled on Proton pump inhibitors and remained largely symptom free.