Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature

Abstract

Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient's history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone.

Endoscopic versus Surgical Intervention for Jejunal Bezoar Formation

“…Bezoar formation is a rare cause of intestinal obstruction 8. When found, they are commonly associated with patients who have impaired gastric motility as a result of prior gastric surgery, such as Billroth I or II operations, or diabetic gastroparesis 1 , 3 , 7 , 9.…”

“…For these reasons, the patient in this case, who was diabetic with a prior history of a hepaticojejunostomy, was particularly susceptible to bezoar formation as a cause of her small bowel obstruction. Nevertheless, only 4% of small bowel obstructions are due to bezoars in the GI tract8, and therefore clinicians must maintain a high level of suspicion in the appropriate patient population. Early diagnosis is crucial because obstructive bezoars can cause severe complications, including GI ulceration and pressure necrosis 8…”

“…Surgical removal is considered when one or more of these methods have failed 18. Intestinal bezoars, on the other hand, are conventionally treated via surgical intervention 8 , 18-20. The optimal surgical management includes laparoscopy for small to moderate bezoars or exploratory laparotomy for larger bezoars with enterotomy and evacuation 8.…”

“…Reports of bezoars causing GI obstruction dates as far back as the late 18th century 7. Depending on the size and location of a bezoar, some may remain undetected, while others present with symptoms such as abdominal pain, nausea, vomiting, GI bleeding, and ileus or small bowel obstruction 8. While traditionally removed via a surgical approach3 , 9, there are a select few cases of obstructive intestinal bezoars successfully managed via endoscopic removal.…”

“…While traditionally removed via a surgical approach3 , 9, there are a select few cases of obstructive intestinal bezoars successfully managed via endoscopic removal. Endoscopic treatment of bezoars causing intestinal obstruction is challenging and scarcely reported in the literature 4 , 8…”