Bezoar due to laxatives: a rare cause of acute small bowel obstruction

Abstract

Bezoar due to laxatives: a rare cause of acute small bowel obstruction We present the case of a 45-year-old gentleman who presented to a regional tertiary referral hospital with a 24-hour history of epigastric colicky pain, abdominal distension, vomiting and obstipation. There was no background surgical or medical history and no regular medications aside from twice-daily Normacol ® after meals (without anyadditional fluid). This was commenced one week prior to this presentation to improve regularity of his bowel motions. On examination, he had normal vital signs and was afebrile. His abdomen was soft but distended with mild epigastric tenderness, no peritonism and no herniae. Laboratory investigations were unremarkable. Computed tomography (CT) imaging of the abdomen with intravenous contrast showed a proximal small bowel obstruction (Fig. 1) with a transition point in the left upper abdomen. He was managed with nasogastric tube decompression, intravenous fluids and taken to the operating theatre for an urgent diagnostic laparoscopy. Intra-operatively, there were dilated loops of jejunum with a transition point into collapsed bowel approximately 50 cm from the ligament of Treitz. Small bowel contents were not able to be progressed beyond this point; hence, an intra-luminal or mural obstruction was suspected. A 10 cm midline abdominal incision was made for extracorporeal assessment of the jejunum, which contained an obstructing bezoar of soft rubbery consistency. At the site of obstruction, a 2 cm enterotomy was made and 47 g of yellow sponge-like material was removed (Fig. 2), which appeared macroscopically identical to Normacol granules. After enterotomy closure, the remainder of the small bowel run was normal and no resection was required. Histopathological examination of the obstructing luminal contents reported a mix of mucoid and foreign granular material, consistent with bezoar.