A rare case of bowel perforation caused by a phytobezoar: Case report

The authors describe a case of spontaneous ileal perforation in bowel obstruction caused by a phytobezoar. A young woman arrived at the Emergency Department with abdominal pain. The clinical story of the patient revealed a first neonatal surgery for meconium ileum, appendectomy and resection of a bleeding Meckel diverticulum. On admission, abdominal X-Ray and US were performed, showing distension of proximal bowel loops with gas and fluid levels and a thickened ileum loop with a conspicuous fluid level in peritoneal cavity. Due to the worsening of pain and with a suspicion of bowel perforation, the patient underwent urgent surgery. A complete obstruction of the last ileal loop by a phytobezoar was revealed. We proceeded, after enterotomy, to extract the vegetal concretion by milking the bowel. Ileal phytobezoars are an uncommon cause of obstruction and diagnosis is possible thanks to abdominal X-Ray, US, barium and CT. In our patient, the worsening of pain and the presence of endoabdominal fluid at the ultrasound imposed urgent surgical operation even without CT. The diagnosis of this unusual condition could be very difficult, indeed we decide for surgical approach even without a sure etiological diagnosis. Laparoscopy was not performed because of the previous multiple surgical accesses. This anomalous management resulted right and according to literature, in fact guidelines for this kind of patients provide an open surgical approach with enterotomy and milking of the bowel.