Acute upper gastrointestinal obstruction due to foreign body ingestion is rare (<6 % of all small intestinal obstruction). Bezoars tend to grow slowly and only thereafter cause obstruction, if any. Rapid formation of a bezoar within hours of ingestion of the offending substance is a unique entity. Here, we present a case of a 22-year-old Indian male who was brought in the emergency department with history of ingesting chemicals used for refrigerator insulation, with suicidal intent. Within hours, he was operated for suspected perforation. And on the operation table, we came across surprisingly a cast extending from the whole of the esophagus to as far as 2 ft of proximal jejunum! Probably the first of its kind ever known! And no breach in the gut could be found in spite of free gas under the dome of diaphragm, probably due to the chemicals sealing the rent as it solidified! Keywords Bezoar . Lithobezoar . Polyurethane . Cast . Small intestine obstruction Case ReportWe report a case of a 22-year-old Indian male working in a deep-freeze factory, who presented 3 h following ingestion of two liquid chemicals, known to him, with suicidal intent. He was severely nauseating and having severe abdominal pain. Vomitus contained only saliva admixed with trace of blood probably due to retching. On examination, his pulse was 92/min and blood pressure was 136/82 mm of Hg. There was a dome-shaped bulge in epigastrium, non-tender, hard in consistency, incompressible, and dull on percussion. Gastric lavage failed as Ryle's tube could not be passed.Routine investigations showed the following: Hb 15, TLC 25000, neutrophils 77 %, blood sugar (random) 362, blood urea 39, serum creatinine 1.49, serum uric acid 8.19, SGOT 40, SGPT 49, S. total bilirubin 1.42, S. Na +146, S.K. +4.3, ECG within normal limits.X-ray abdomen showed a grossly distended stomach shadow which occupied almost the entire film and was homogeneously radiolucent. There was gas under the right dome of the diaphragm. This aroused the doubt of a cast, which might be expanding, and the gut wall giving way.The implicated chemicals were brought. There were two distinct liquids, which on mixing, showed exothermic reaction, and formed an expanding foamy solid in 5-10 min assuming the shape of the container.Patient was taken for emergency exploratory laparotomy (Fig. 1). No free fluid was found in the peritoneal cavity, suggesting that the cast might have sealed the perforation. The whole of the stomach, duodenum, and proximal 2 ft of jejunum were distended and spongy hard in consistency, and their shape could not be molded. Longitudinal anterior gastrotomy was done and the gastric cast, including the entire esophageal cast, was retrieved in toto (Fig. 2). Another incision was given over jejunum at the distal end of the cast.
Retro rectal or presacral tumors are uncommon lesions. It can be difficult to diagnose as presenting signs and symptoms are usually nonspecific. Retro rectal lesions can be congenital or acquired, benign or malignant. Children can also have retro rectal masses like anterior meningocele, teratomas or cystic teratomas. FNAC or biopsy usually is not required as imaging can provide a reasonably good diagnosis. Cross-sectional imaging is essential in evaluating these lesions to determine the optimal surgical approach and the extent of resection. Surgery is the mainstay of treatment as it establishes the diagnosis and prevents the adverse consequences associated with malignant degeneration and secondary bacterial infection. The outcomes for patients with benign presacral tumors are favourable.
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