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Author: Sophia Nguyen, BA - University of
Colorado School of Medicine, Class of 2012
Introduction: Bezoars are accumulations of
indigestible material such as vegetable matter, hair or medications
in the gastrointestinal tract. These concretions are most
frequently found in the stomach and can cause serious medical
problems such as bowel obstruction, impaction and perforation.
Case Presentation: A 41-year-old female with a
history of bipolar disorder and iron deficiency anemia presented to
the emergency department with 2 days of severe stabbing left lower
quadrant (LLQ) abdominal pain radiating to the left groin. The pain
was unchanged with food intake or position. She had not had a bowel
movement (BM) in 3 days. Her medical history revealed occasional
pica, a previous ectopic pregnancy and regular menstruation without
menorrhagia. She smoked tobacco and was on parole for previous
cocaine use. On physical exam, her vital signs were normal and she
had LLQ abdominal tenderness but no peritoneal signs. An initial
work-up revealed a WBC 14K/uL, hematocrit 31%, MCV 78fl, ferritin
69g/L and iron saturation 3%. Urinalysis, urine hCG and
comprehensive metabolic panel were normal. A CT KUB showed a
strictured segment of the sigmoid colon with mild pericolonic
inflammatory fat stranding around the descending colon seemingly
most consistent with colitis. Intravenous metronidazole and
ampicillin-sulbactam were initiated for treatment of
Due to continued constipation and concern for a stricture and
mechanical obstruction, a flexible sigmoidoscopy was scheduled.
Upon re-interviewing the patient, she admitted to recent
consumption of paper in the amount of 2 novels. Subsequent
sigmoidoscopy revealed a large bezoar composed of typing paper with
visible printed words in the sigmoid colon causing complete
obstruction. Neither snare nor roth net were able to remove the
bezoar. This area was flushed with 1.5 L of tap water which allowed
stool to pass and revealed underlying mucosal ulceration and large
diverticula. With daily enemas and a liquid diet, the patient was
able to pass the bezoar and resumed normal BMs.
Discussion: Given the inherent ability of
bezoars to mimic various gastrointestinal maladies, clinicians
should have a high index of suspicion when evaluating a patient
with abdominal pain, a history of pica and underlying psychiatric
illness. Most commonly, bezoars are diagnosed by endoscopy and are
composed of hair. Only few cases of paper bezoars causing colonic
ischemia have been reported and these have been diagnosed by
laparotomy. Thus, this is a rare case of a colonic xylobezoar
diagnosed and treated via flexible sigmoidoscopy. Furthermore, this
patient likely had iron deficiency anemia caused by her mucosal
ulceration and diverticula, thereby escalating her paper craving.
Early recognition could help shorten hospitalization time, allow
for diagnostic and therapeutic endoscopy as opposed to surgery and
decrease complications associated with bezoars.
Back to May
2012 Issue of IMpact