1990, The British Journal of Radiology, 63, 367-368

Case of the month A Chinese puzzle By J . W. Williams, FRCS and M. C. Collins, FRCR Department of Radiology, Royal Hallamshire Hospital, Sheffield

(Received March 1989 )

A 39-year-old Chinese waiter presented with a 5 week history of intermittent epigastric pain, exacerbated after eating and increasing over the 3 days preceding admission with associated retching. Previous medical history included a vagotomy and gastro-enterostomy for duodenal ulcer many years earlier, and similar symptoms had settled with conservative management in the past. Examination revealed abdominal distension and highpitched bowel sounds. A plain abdominal radiograph was obtained (Fig. 1). The patient initially settled after naso-gastric suction and intravenous fluids, but could not tolerate the reintroduction of oral fluids. What signs are present on the plain abdominal radiograph?

Figure 1. A plain abdominal radiograph on initial examination.

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Case of the month

Figure 2. Radiographs from the barium meal and follow-through examination demonstrating extensive granular filling defects within the stomach. Note the gastro-enterostomy (arrow) and the small bowel obstruction.

Figure 1 shows distended small bowel loops and a granular mass within the transversely lying stomach. A barium meal and follow-through examination was performed but the patient's condition deteriorated and he was taken to theatre for laparotomy before the procedure could be completed. Two radiographs from the examination are shown (Fig. 2). These demonstrate extensive granular filling defects, probably phytobezoars, within the stomach. The gasto-enterostomy is patent and there is small bowel obstruction. At operation, the whole small bowel was found to be distended, because of the obstruction of the terminal ileum by a phytobezoar composed largely of rice. The stomach could not be assessed because of dense adhesions from previous surgery. Discussion

Phytobezoars are an uncommon cause of small bowel obstruction, comprising only 2.9% of an Australian series (Vellar et al, 1986). However, a history of gastrectomy, vagotomy and drainage procedure or jejunal

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diverticula makes it more likely (Mir & Mir, 1973; King et al, 1985). When they are clinically suspected, gastroscopy prior to surgery will confirm the presence of any gastric bezoars and allow their endoscopic removal or proteolytic dissolution and prevent acute post-surgical recurrence. Prophylaxis is achieved by giving dietary advice to avoid fibrous vegetables and stone-fruits to post-operative patients. References KING, P. M., BIRD, D. R. & EREMIN, O., 1985. Enterolith

obstruction of the small bowel. Journal of the Royal College of Surgeons of Edinburgh, 30, 269-270. MIR, A. M. & MIR, M. A., 1973. Phytobezoars after vagotomy with drainage or resection. British Journal of Surgery, 60, 846-849. VELLAR, D. J., VELLAR, I. D., Pucius, R. & STEEDMAN, P. K.,

1986. Phytobezoars—an overlooked cause of small bowel obstruction following vagotomy and drainage operations for duodenal ulcer. Australian and New Zealand Journal of Surgery, 56, 635-638.

The British Journal of Radiology, May 1990

Case of the month. A Chinese puzzle.

1990, The British Journal of Radiology, 63, 367-368 Case of the month A Chinese puzzle By J . W. Williams, FRCS and M. C. Collins, FRCR Department of...
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