Clin J Gastroenterol (2011) 4:104–107 DOI 10.1007/s12328-011-0212-2
CASE REPORT
Impacted foreign body in the sigmoid colon presenting as recurrent diverticulitis Jaime Ramos • Dorothy E. Dean • Elias Tarakji Jeremy Rich
•
Received: 13 December 2010 / Accepted: 8 February 2011 / Published online: 3 March 2011 Ó Springer 2011
Abstract We report on a patient with left-sided abdominal pain thought to be caused by recurring diverticulitis. Computed tomography of the sigmoid colon revealed diverticulosis without the presence of a foreign body. During colonoscopy, a phytobezoar in the form of a vegetable stem was discovered transversely impacted within two diverticular openings in the lumen of the sigmoid colon. A localized inflammatory reaction was present without obstruction or perforation. After endoscopic removal of the phytobezoar, the abdominal pain resolved. The patient’s presumed diverticulitis was an inflammatory reaction caused by the phytobezoar. This case highlights the importance of early detection and endoscopic removal of a colonic foreign body to prevent abscess formation, fistulas, obstruction, perforation, or peritonitis. Foreign bodies masquerading as colonic diverticulitis should be considered in the absence of more common diseases.
J. Ramos HealthCare Partners Medical Group, 9810 Las Tunas Drive, Temple City, CA 91780, USA D. E. Dean Summit County Medical Examiner’s Office, 85 North Summit Street, Akron, OH 44308, USA E. Tarakji Valley Gastroenterology Consultants, 488 East Santa Clara Street, Suite #103, Arcadia, CA 91006, USA J. Rich (&) HealthCare Partners Institute for Applied Research and Education, 19191 South Vermont Avenue, Suite #200, Torrance, CA 90502, USA e-mail: [email protected]
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Keywords Foreign body Phytobezoar Diverticulitis Sigmoid colon
Introduction Gastrointestinal bezoars consist of poorly digested material commonly found in the stomach and small bowel and may cause bowel obstruction, impaction, or perforation [1–4]. Phytobezoars retain a similar composition to the fruits and vegetables from which they are formed, consisting of nondigestible fibers such as cellulose, lignin, hemicellulose, and tannins [3]. A high-fiber diet, incomplete mastication, reduced gastric secretion, and decreased gastrointestinal motility from autonomic neuropathy can predispose patients to phytobezoar formation [2, 4]. Gastrointestinal bezoars are frequently found within the small intestine, particularly the terminal ileum and jejunum. Formation is increased by truncal vagotomy or gastroduodenal resection for treatment of peptic ulcer disease. These procedures result in hypoacidity and delayed gastric emptying thereby promoting bezoar formation. A phytobezoar in the colon is rare, and usually presents with obstruction or perforation [1, 2]. We report on a patient with left-sided abdominal pain thought to be caused by recurring diverticulitis. Computed tomography (CT) of the sigmoid colon revealed diverticulosis without the presence of a foreign body. During colonoscopy, a phytobezoar in the form of a vegetable stem was discovered in the lumen of the sigmoid colon causing a localized inflammatory reaction without obstruction or perforation. The colonoscopist initially thought the foreign object was a ‘‘chicken bone’’ based on its shape, length, and slightly flared, rounded ends. This case highlights the importance of early detection and endoscopic removal of a
Clin J Gastroenterol (2011) 4:104–107
colonic foreign body to prevent abscess formation, fistulas, obstruction, perforation, or peritonitis.
Case report A 67-year-old woman presented to her primary care physician with intractable lower left quadrant and left flank pain for over a year. A colonoscopy was performed and revealed colonic inflammation presumed to be diverticulitis. There was no foreign body visualized. The patient was treated with broad-spectrum antibiotics which partially reduced her pain. A year later, she became a patient at our medical group. She presented with recalcitrant abdominal pain in the lower left quadrant with a history of sigmoid diverticulosis; the initial abdominal pain had improved with antibiotics. She denied nausea, vomiting, constipation, diarrhea, rectal bleeding, fever or chills and had no urinary symptoms. She denied any history of diabetes, neurologic or psychologic disorders, peptic ulcer disease, intra-abdominal surgery, or abdominal trauma. The patient also denied dietary changes, food allergies, or recent travel. Her bowel movements were regular and well-formed without hematochezia. The patient’s past medical history was significant for hypertension, hypothyroidism, gastroesophageal reflux disease, and degenerative joint disease. She was diagnosed with a hypercoagulable state following two spontaneous pulmonary emboli and was maintained on long-term anticoagulation therapy with warfarin. The patient’s medication included lisinopril, omeprazole, levothyroxine, and outpatient administration of enoxaparin and warfarin. The patient was on a vitamin K-restricted diet limiting green leafy vegetables due to warfarin use. Laboratory values obtained at our clinic included complete blood counts with differential. The white blood cell count was within normal limits. Hemoglobin, hematocrit, MCV, and MCH levels were 11.6 g/dl, 36.4%, 89 fl, 29.3 pg, respectively; an iron profile was not performed at this time. C-reactive protein was not measured because this laboratory test is not necessary to diagnose diverticulitis [5]. Laboratory results 6 months later reflected mild anemia parameters including hemoglobin of 10.5 g/dl and hematocrit of 32.8%. MCH was 26.7 pg, and MCV was borderline as it had decreased to 83 fl. These parameters were interpreted as anemia with borderline microcytic features. Microcytic anemia was presumed to be caused by colonic blood loss due to chronic diverticulitis. No other markers of inflammation were obtained and an iron profile was not performed. A CT scan with intravenous and oral contrast revealed sigmoid diverticula without pericolonic fat stranding,
105
colonic wall thickening or peridiverticular abscess. CT findings suggestive of a foreign body were not visualized (Fig. 1). The patient was offered reassurance, advised to monitor her symptoms, and to consume iron-rich foods. Given the patient’s prolonged abdominal pain and anemia, she was referred for a gastroenterology consultation. Due to the persistence of symptoms, and the development of microcytic anemia, a colonoscopy was performed. Because of the high risk of embolic events if anticoagulation therapy was withdrawn, a bridge of enoxaparin injections was administered prior to colonoscopy, and warfarin was withheld. A foreign object measuring 2.5 cm in length was visualized endoscopically (Fig. 2). The object was transversely embedded within two diverticular openings across the lumen of the sigmoid colon with a severe inflammatory reaction surrounding the two diverticulae involved. There was no obstruction or perforation present at this time. The colonoscopist thought the foreign object was a ‘‘chicken bone’’ based on its shape, length, and slightly flared, rounded ends. The risk of perforation by leaving the ‘‘chicken bone’’ in place was greater than the risk of removal. The gastroenterologist removed the foreign body endoscopically with retrieval forceps (Fig. 3). Removal of the foreign body was not complicated by bleeding or perforation. Broad-spectrum antibiotics were empirically administered. Subsequent pathologic examination revealed that the ‘‘chicken bone’’ was a phytobezoar. After removal, the patient’s abdominal pain resolved completely; however, the microcytic anemia did not resolve and the patient was referred to a hematologist for further evaluation. Iron deficiency anemia was diagnosed and corrected with oral iron therapy.
Discussion A foreign body caused an inflammatory reaction in the sigmoid colon and presented as diverticulitis. In this case, the phytobezoar did not cause obstruction, fecal impaction, or intestinal wall perforation. The foreign body was embedded transversely within the lumen of the colon but had a narrow diameter which may have prevented colonic obstruction (Fig. 2). Although an inflammatory reaction surrounding the colonic wall was visualized endoscopically, perforation was absent. The absence of perforation could possibly be explained by the bezoar’s rounded tips (Fig. 3). The patient did not have a medical history predisposing her to phytobezoar formation; incomplete mastication may have been responsible. The patient had colonic diverticula before the vegetable material became lodged. Based upon the resolution of the patient’s abdominal pain after foreign
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Fig. 1 CT scan of the sigmoid colon shows diverticulosis Fig. 3 Endoscopic removal of the ‘‘chicken bone’’ later confirmed as vegetable matter
Fig. 2 ‘‘Chicken bone’’ transversely positioned within the sigmoid lumen
body removal, we can conclude that the phytobezoar was responsible for her abdominal pain from the outset. There was no evidence of systemic inflammation as would be manifested by leukocystosis, suggesting that the patient’s abdominal pain may have not been caused by diverticulitis. The patient’s first colonoscopy revealed colonic inflammation which was probably secondary to phytobezoar irritation as opposed to acute diverticulitis; however, there was no record of phytobezoar visualization during this colonoscopy. The phytobezoar may have been obscured by stool secondary to incomplete bowel preparation, or colonic edema secondary to foreign body. The CT scan showed inflammatory changes within the sigmoid colon; however, the phytobezoar was not visualized. The plant material was most likely not sufficiently
123
radiodense to appear on CT. Because of the radiolucent nature of plant materials, false-negatives can occur with CT scans [6, 7]. We speculate that the inflammatory reaction from the foreign body was too localized to be detected on a CT scan as opposed to acute diverticulitis that generally involves a longer segment of colon. Conceivably, if the foreign body was osseous or calcified, it would likely be detected on a CT scan. Foreign body entrapment in the sigmoid colon is uncommon. Unlike the more proximal parts of the luminal gastrointestinal tract, the colonic lumen is wide enough to allow the passage of most indigestible objects such as the size of the vegetable matter in this case. The entrapment and impaction of this foreign object is unlikely to have happened in the absence of underlying diverticular disease. Moreover, colonic foreign body entrapment is not a described cause of iron deficiency anemia. The patient’s iron deficiency was likely due to chronic gastrointestinal blood loss associated with the inflammatory reaction in the sigmoid colon due to the entrapment of the foreign body for a lengthy period of time, exceeding a year in this particular patient. She was also on anticoagulation therapy which likely accentuated blood loss. Foreign body entrapment in the colon is not generally considered in the differential diagnosis of acute diverticulitis. If the phytobezoar had not been identified and treated, complications could have developed including perforation, abscess formation, bleeding, or stricture. This case suggests that foreign body entrapment should be considered when the diagnosis of acute diverticulitis does not present on CT, becomes recurrent, and does not respond to antibiotic regimens.
Clin J Gastroenterol (2011) 4:104–107 Acknowledgments The authors gratefully acknowledge Dr. Thomas Aguirre for discussions and helpful suggestions, and Cynthia Sanko for technical assistance. Conflict of interest The authors declare that they have no conflicts of interest related to the publication of this manuscript.
References 1. Larson J, Vender R, Camuto P, Scholhamer C, Mansourian V. Phytobezoar of pure vegetable matter causing colonic obstruction. J Clin Gastroenterol. 1995;20(2):176–7. 2. Chisholm EM, Leong HT, Chung SC, Li AK. Phytobezoar: an uncommon cause of small bowel obstruction. Ann R Coll Surg Engl. 1992;74(5):342–4.
107 3. Lee SJ, Chu SJ, Tsai SH. Colonic phytobezoar. Emerg Med J. 2007;24(7):518. 4. Fetzner UK, Oana IC, Bu¨schel P, Kasch R, Alakus H, Moenig SP, Herbold T, Stippel DL, Scheele J. Phytobezoar: impact of differential diagnosis and difficulties in technical diagnostics. Dig Surg. 2010;27(4):339. 5. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007;357(20):2057–66. 6. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Malley JS, Raddavi HM, Vargo JJ, Waring JP, Farelli RD, Wheeler-Harbough J. Guideline for the management of foreign bodies. Gastrointest Endosc. 2002;55(7):802–6. 7. Eng JGH, Aks SE, Marcus C, Issleib S. False-negative abdominal CT scan in a cocaine body stuffer. Am J Emerg Med. 1999; 17:702–4.
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CASE REPORT
Impacted foreign body in the sigmoid colon presenting as recurrent diverticulitis Jaime Ramos • Dorothy E. Dean • Elias Tarakji Jeremy Rich
•
Received: 13 December 2010 / Accepted: 8 February 2011 / Published online: 3 March 2011 Ó Springer 2011
Abstract We report on a patient with left-sided abdominal pain thought to be caused by recurring diverticulitis. Computed tomography of the sigmoid colon revealed diverticulosis without the presence of a foreign body. During colonoscopy, a phytobezoar in the form of a vegetable stem was discovered transversely impacted within two diverticular openings in the lumen of the sigmoid colon. A localized inflammatory reaction was present without obstruction or perforation. After endoscopic removal of the phytobezoar, the abdominal pain resolved. The patient’s presumed diverticulitis was an inflammatory reaction caused by the phytobezoar. This case highlights the importance of early detection and endoscopic removal of a colonic foreign body to prevent abscess formation, fistulas, obstruction, perforation, or peritonitis. Foreign bodies masquerading as colonic diverticulitis should be considered in the absence of more common diseases.
J. Ramos HealthCare Partners Medical Group, 9810 Las Tunas Drive, Temple City, CA 91780, USA D. E. Dean Summit County Medical Examiner’s Office, 85 North Summit Street, Akron, OH 44308, USA E. Tarakji Valley Gastroenterology Consultants, 488 East Santa Clara Street, Suite #103, Arcadia, CA 91006, USA J. Rich (&) HealthCare Partners Institute for Applied Research and Education, 19191 South Vermont Avenue, Suite #200, Torrance, CA 90502, USA e-mail: [email protected]
123
Keywords Foreign body Phytobezoar Diverticulitis Sigmoid colon
Introduction Gastrointestinal bezoars consist of poorly digested material commonly found in the stomach and small bowel and may cause bowel obstruction, impaction, or perforation [1–4]. Phytobezoars retain a similar composition to the fruits and vegetables from which they are formed, consisting of nondigestible fibers such as cellulose, lignin, hemicellulose, and tannins [3]. A high-fiber diet, incomplete mastication, reduced gastric secretion, and decreased gastrointestinal motility from autonomic neuropathy can predispose patients to phytobezoar formation [2, 4]. Gastrointestinal bezoars are frequently found within the small intestine, particularly the terminal ileum and jejunum. Formation is increased by truncal vagotomy or gastroduodenal resection for treatment of peptic ulcer disease. These procedures result in hypoacidity and delayed gastric emptying thereby promoting bezoar formation. A phytobezoar in the colon is rare, and usually presents with obstruction or perforation [1, 2]. We report on a patient with left-sided abdominal pain thought to be caused by recurring diverticulitis. Computed tomography (CT) of the sigmoid colon revealed diverticulosis without the presence of a foreign body. During colonoscopy, a phytobezoar in the form of a vegetable stem was discovered in the lumen of the sigmoid colon causing a localized inflammatory reaction without obstruction or perforation. The colonoscopist initially thought the foreign object was a ‘‘chicken bone’’ based on its shape, length, and slightly flared, rounded ends. This case highlights the importance of early detection and endoscopic removal of a
Clin J Gastroenterol (2011) 4:104–107
colonic foreign body to prevent abscess formation, fistulas, obstruction, perforation, or peritonitis.
Case report A 67-year-old woman presented to her primary care physician with intractable lower left quadrant and left flank pain for over a year. A colonoscopy was performed and revealed colonic inflammation presumed to be diverticulitis. There was no foreign body visualized. The patient was treated with broad-spectrum antibiotics which partially reduced her pain. A year later, she became a patient at our medical group. She presented with recalcitrant abdominal pain in the lower left quadrant with a history of sigmoid diverticulosis; the initial abdominal pain had improved with antibiotics. She denied nausea, vomiting, constipation, diarrhea, rectal bleeding, fever or chills and had no urinary symptoms. She denied any history of diabetes, neurologic or psychologic disorders, peptic ulcer disease, intra-abdominal surgery, or abdominal trauma. The patient also denied dietary changes, food allergies, or recent travel. Her bowel movements were regular and well-formed without hematochezia. The patient’s past medical history was significant for hypertension, hypothyroidism, gastroesophageal reflux disease, and degenerative joint disease. She was diagnosed with a hypercoagulable state following two spontaneous pulmonary emboli and was maintained on long-term anticoagulation therapy with warfarin. The patient’s medication included lisinopril, omeprazole, levothyroxine, and outpatient administration of enoxaparin and warfarin. The patient was on a vitamin K-restricted diet limiting green leafy vegetables due to warfarin use. Laboratory values obtained at our clinic included complete blood counts with differential. The white blood cell count was within normal limits. Hemoglobin, hematocrit, MCV, and MCH levels were 11.6 g/dl, 36.4%, 89 fl, 29.3 pg, respectively; an iron profile was not performed at this time. C-reactive protein was not measured because this laboratory test is not necessary to diagnose diverticulitis [5]. Laboratory results 6 months later reflected mild anemia parameters including hemoglobin of 10.5 g/dl and hematocrit of 32.8%. MCH was 26.7 pg, and MCV was borderline as it had decreased to 83 fl. These parameters were interpreted as anemia with borderline microcytic features. Microcytic anemia was presumed to be caused by colonic blood loss due to chronic diverticulitis. No other markers of inflammation were obtained and an iron profile was not performed. A CT scan with intravenous and oral contrast revealed sigmoid diverticula without pericolonic fat stranding,
105
colonic wall thickening or peridiverticular abscess. CT findings suggestive of a foreign body were not visualized (Fig. 1). The patient was offered reassurance, advised to monitor her symptoms, and to consume iron-rich foods. Given the patient’s prolonged abdominal pain and anemia, she was referred for a gastroenterology consultation. Due to the persistence of symptoms, and the development of microcytic anemia, a colonoscopy was performed. Because of the high risk of embolic events if anticoagulation therapy was withdrawn, a bridge of enoxaparin injections was administered prior to colonoscopy, and warfarin was withheld. A foreign object measuring 2.5 cm in length was visualized endoscopically (Fig. 2). The object was transversely embedded within two diverticular openings across the lumen of the sigmoid colon with a severe inflammatory reaction surrounding the two diverticulae involved. There was no obstruction or perforation present at this time. The colonoscopist thought the foreign object was a ‘‘chicken bone’’ based on its shape, length, and slightly flared, rounded ends. The risk of perforation by leaving the ‘‘chicken bone’’ in place was greater than the risk of removal. The gastroenterologist removed the foreign body endoscopically with retrieval forceps (Fig. 3). Removal of the foreign body was not complicated by bleeding or perforation. Broad-spectrum antibiotics were empirically administered. Subsequent pathologic examination revealed that the ‘‘chicken bone’’ was a phytobezoar. After removal, the patient’s abdominal pain resolved completely; however, the microcytic anemia did not resolve and the patient was referred to a hematologist for further evaluation. Iron deficiency anemia was diagnosed and corrected with oral iron therapy.
Discussion A foreign body caused an inflammatory reaction in the sigmoid colon and presented as diverticulitis. In this case, the phytobezoar did not cause obstruction, fecal impaction, or intestinal wall perforation. The foreign body was embedded transversely within the lumen of the colon but had a narrow diameter which may have prevented colonic obstruction (Fig. 2). Although an inflammatory reaction surrounding the colonic wall was visualized endoscopically, perforation was absent. The absence of perforation could possibly be explained by the bezoar’s rounded tips (Fig. 3). The patient did not have a medical history predisposing her to phytobezoar formation; incomplete mastication may have been responsible. The patient had colonic diverticula before the vegetable material became lodged. Based upon the resolution of the patient’s abdominal pain after foreign
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Clin J Gastroenterol (2011) 4:104–107
Fig. 1 CT scan of the sigmoid colon shows diverticulosis Fig. 3 Endoscopic removal of the ‘‘chicken bone’’ later confirmed as vegetable matter
Fig. 2 ‘‘Chicken bone’’ transversely positioned within the sigmoid lumen
body removal, we can conclude that the phytobezoar was responsible for her abdominal pain from the outset. There was no evidence of systemic inflammation as would be manifested by leukocystosis, suggesting that the patient’s abdominal pain may have not been caused by diverticulitis. The patient’s first colonoscopy revealed colonic inflammation which was probably secondary to phytobezoar irritation as opposed to acute diverticulitis; however, there was no record of phytobezoar visualization during this colonoscopy. The phytobezoar may have been obscured by stool secondary to incomplete bowel preparation, or colonic edema secondary to foreign body. The CT scan showed inflammatory changes within the sigmoid colon; however, the phytobezoar was not visualized. The plant material was most likely not sufficiently
123
radiodense to appear on CT. Because of the radiolucent nature of plant materials, false-negatives can occur with CT scans [6, 7]. We speculate that the inflammatory reaction from the foreign body was too localized to be detected on a CT scan as opposed to acute diverticulitis that generally involves a longer segment of colon. Conceivably, if the foreign body was osseous or calcified, it would likely be detected on a CT scan. Foreign body entrapment in the sigmoid colon is uncommon. Unlike the more proximal parts of the luminal gastrointestinal tract, the colonic lumen is wide enough to allow the passage of most indigestible objects such as the size of the vegetable matter in this case. The entrapment and impaction of this foreign object is unlikely to have happened in the absence of underlying diverticular disease. Moreover, colonic foreign body entrapment is not a described cause of iron deficiency anemia. The patient’s iron deficiency was likely due to chronic gastrointestinal blood loss associated with the inflammatory reaction in the sigmoid colon due to the entrapment of the foreign body for a lengthy period of time, exceeding a year in this particular patient. She was also on anticoagulation therapy which likely accentuated blood loss. Foreign body entrapment in the colon is not generally considered in the differential diagnosis of acute diverticulitis. If the phytobezoar had not been identified and treated, complications could have developed including perforation, abscess formation, bleeding, or stricture. This case suggests that foreign body entrapment should be considered when the diagnosis of acute diverticulitis does not present on CT, becomes recurrent, and does not respond to antibiotic regimens.
Clin J Gastroenterol (2011) 4:104–107 Acknowledgments The authors gratefully acknowledge Dr. Thomas Aguirre for discussions and helpful suggestions, and Cynthia Sanko for technical assistance. Conflict of interest The authors declare that they have no conflicts of interest related to the publication of this manuscript.
References 1. Larson J, Vender R, Camuto P, Scholhamer C, Mansourian V. Phytobezoar of pure vegetable matter causing colonic obstruction. J Clin Gastroenterol. 1995;20(2):176–7. 2. Chisholm EM, Leong HT, Chung SC, Li AK. Phytobezoar: an uncommon cause of small bowel obstruction. Ann R Coll Surg Engl. 1992;74(5):342–4.
107 3. Lee SJ, Chu SJ, Tsai SH. Colonic phytobezoar. Emerg Med J. 2007;24(7):518. 4. Fetzner UK, Oana IC, Bu¨schel P, Kasch R, Alakus H, Moenig SP, Herbold T, Stippel DL, Scheele J. Phytobezoar: impact of differential diagnosis and difficulties in technical diagnostics. Dig Surg. 2010;27(4):339. 5. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007;357(20):2057–66. 6. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Malley JS, Raddavi HM, Vargo JJ, Waring JP, Farelli RD, Wheeler-Harbough J. Guideline for the management of foreign bodies. Gastrointest Endosc. 2002;55(7):802–6. 7. Eng JGH, Aks SE, Marcus C, Issleib S. False-negative abdominal CT scan in a cocaine body stuffer. Am J Emerg Med. 1999; 17:702–4.
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