Volume 2, Issue 4 | July 2015
Image | Colon

Rectal Pain and the Colonic Crunch Sign

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Syed Kashif Mahmood, MD, MPH

Department of Gastroenterology, Lahey Clinic, Burlington, MA

ACG Case Rep J 2015;2(4):200-201. http://dx.doi.org/10.14309/crj.2015.56. Published: July 9, 2015.

Case Report

A 31-year-old man presented to a local hospital with lower abdominal and rectal pain. He reported consuming a large bag of sunflower seeds (described as chewing and sucking unshelled seeds). The day after ingestion he noted progressive abdominal pain and difficulty passing stool. Due to the pain, he attempted a self-disimpaction with inability to clear a palpable mass, prompting him to present to the emergency room. Vital signs were stable on presentation and bedside physical examination revealed a non-tender abdomen.

Laboratory work was only significant for leukocytosis of 17,000 cells/μL. Abdominal X-ray (Figure 1) suggested rectal fecal loading. Digital rectal exam revealed a “crunchy” mass. The patient underwent flexible sigmoidoscopy with visualization of a large clump of sunflower seeds (Figure 2), but it was not possible to remove them with either the water jet or snare net. He underwent colonoscopy under general anesthesia, resulting in complete evacuation. On colonoscopy, mucosal erythema and edema was noted at site of seed impaction, which appeared secondary to irritation from the bezoar. The remainder of examined colon to cecum appeared normal, without any stricture, polyp, or mass. The patient was advised to avoid ingesting sunflower seeds and was discharged home.

Mahmood-Figure-1

Figure 1. Rectal phytobezoar shown on abdominal X-ray.

Rectal bezoars are rare, since most food bezoars cause upper gastrointestinal obstructive symptoms.1 Furthermore, it is unusual to encounter rectal sunflower seed bezoars in adults. Digital rectal exam in the presence of a phytobezoar can sometimes reveal a crunchy mass of seeds at the anal verge, dubbed as the “colonic crunch” sign.2,3

Mahmood-Figure-2

Figure 2. Sunflower seeds in the rectum shown on sigmoidoscopy.


Disclosures

Author contributions: S. Mahmood procured the images, wrote the manuscript, and is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

Correspondence: Syed Kashif Mahmood, Lahey Clinic, 41 Mall Road, Burlington, MA 01805 (skm@post.harvard.edu).

Received: January 25, 2015; Accepted: April 22, 2015


References

  1. Lowry MH, Shah AN. Sunflower seed rectal bezoar in an adult. Gastrointest Endosc. 2001;53(3):388–389. Article | PubMed
  2. Melchreit R, McGowan G, Hyams JS. “Colonic crunch” sign in sunflower seed bezoar. N Engl J Med. 1984;310(26):1748–1749. Article | PubMed
  3. Larson J, Vender R, Camuto P, et al. Phytobezoar of pure vegetable matter causing colonic obstruction. J Clin Gastroenterol. 1995;20(2):176–177. Article | PubMed

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© 2015 Mahmood et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0.