A 38-year-old woman with no significant past medical history presented to the emergency department with a 1-day history of diffuse abdominal pain. She reported normal bowel movements up to 1 day prior and was unable to pass anything rectally since. There was no report of fever, nausea, vomiting, hematemesis, or melena. Physical exam demonstrated diffuse abdominal tenderness and normal bowel sounds. Laboratory evaluation was unremarkable, and a computed tomography scan of the abdomen and pelvis showed fecal impaction without evidence of obstruction (Figure 1). She was initially treated with tap water enemas without improvement. In the following 24 hours, the patient reported several episodes of hematochezia with a drop of 4.2 g/dL hemoglobin.
Figure 1. Sagittal computed tomography showing fecal impaction in the rectosigmoid colon (arrow).
Colonoscopy revealed a pumpkin seed bezoar impacted at the distal rectum (Figure 2). Removal of the phytobezoar was accomplished with multiple washings and digital removal under general anesthesia. Underneath the bezoar, a circumferential area of ulcerated mucosa was found, and a small bleeding mucosal tear was noted in the proximal ascending colon (Figure 3). The patient tolerated the procedure, and her diet was progressively advanced with significant symptomatic improvement and no further episodes of bleeding.
Figure 2. Pumpkin seed bezoar at the distal rectum.
A phytobezoar, defined as a solid mass of indigestible food materials, is usually reported in the stomach. Rectal seed bezoars are a rare cause of fecal impaction, particularly in Western countries, and are likely related to dietary habits.1 Various types of seeds have been reported to cause fecal impaction, although only 2 cases to date were related to pumpkin seeds.2,3 This is the first reported case of a pumpkin seed bezoar complicated by GI bleeding.
Figure 3. (A) Large circumferential area of exudative ulcerated bleeding mucosa at the distal rectum. (B) Small area of non-exudative bleeding ulcerated mucosa in the proximal ascending colon.
Stercoral ulceration is an ulcer secondary to pressure necrosis usually caused by fecal impaction, and can result in gastrointestinal (GI) bleeding or perforation.4 Some reports suggest development of stercoral ulceration by various foreign bodies.5 In our patient, the bezoar is likely to have formed in the upper GI tract and to have caused mucosal damage during its passage through the proximal colon. Currently there are no treatment guidelines for the management of rectal bezoars. Therapeutic options range from conservative modalities (laxatives, stool softeners) to endoscopic therapy (water jet flush, snare, retrieval basket, forceps) and surgical interventions in refractory cases.
Author contributions: F. Nehme and K. Rowe wrote the manuscript. I. Nassif revised the manuscript for intellectual content. F. Nehme is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Correspondence: Fredy Nehme, 1010 N Kansas St, Wichita, KS 67214 (firstname.lastname@example.org).
Received November 16, 2016; Accepted Feburary 17, 2017
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