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CASE REPORT

A Rare Case of Fatal Bowel Obstruction Secondary


to a Colonic Bezoar
Fiorella Caputo, MD,* Rosario Barranco, MD,* Alessandro Bonsignore, MD, PhD,*
Giulio Fraternali Orcioni, MD,† and Francesco Ventura, MD, PhD*

pumpkins, peels, prunes, and especially persimmons are a risk


Abstract: A bezoar is a mass of undigested, or partially digested, material factor for bezoars formation.7
forming in the lumen of the gastroenteric tract, causing occlusive or Other factors that predispose to the formation of a bezoar
subocclusive events. The most frequent types of bezoars are those com- include systemic diseases that cause alterations of the GI mo-
posed of vegetable fibers, also called phytobezoars, which, by virtue of tility, such as hypothyroidism, postoperative adhesions, diabetes
their high content in cellulose, hemicellulose, and lignin, remain undi- mellitus, Guillain-Barré syndrome, and myotonic dystrophy. Fur-
gested in the stomach and intestines and, from there, can migrate and oc- ther contributing factors are represented by swallowing a large
clude the narrowest portions of the bowel. The areas that are most amount of food without sufficient chewing such as may occur in
frequently affected by occlusive phenomena related to the presence of be- individuals with underlying dental problems especially the elderly,
zoars are the stomach and the small intestine, although colic localizations the use of drugs that slow GI motility, and kidney failure.8–10
are extremely rare. In this article, we have studied the case of a fatal colic However, it was also suggested that a bezoar formation may occur
obstruction caused by a phytobezoar in an 84-year-old woman who was in the absence of any predisposing factor.11 With regard to age, the
found dead at her home. The autopsy revealed that the cause of the obstruc- risk of developing bezoars increases with age: in more than 70%
tion was a large artichoke fragment occluding the central part of the de- of cases, bezoars affect people older than 30.12
scending colon. Additional histological examinations confirmed that the The most frequent locations are the stomach and the small in-
death was attributable to bowel obstruction resulting in acute peritonitis. testine, particularly the terminal ileum and jejunum. The presence
Key Words: bowel obstruction, colonic bezoar, acute peritonitis, hernia, of a bezoar in the large bowel is considered a fairly rare phenom-
sudden unexpected death enon. In this article, we present a rare, fatal case of colonic
phytobezoar in an 84-year-old woman.
(Am J Forensic Med Pathol 2017;00: 00–00)

B ezoars are foreign bodies forming in the lumen of the gastro-


intestinal (GI) tract. This is a rare phenomenon, with an inci-
dence ranging from 0.4% to 4% of all cases of GI obstruction.1
CASE REPORT
An 84-year-old woman, who lived alone, was found dead in
her home. The autopsy was performed 2 days after the discovery
Bezoars can be composed of hair (trichobezoars), vegetable
of the body. The decedent was edentulous and had an old surgical
fibers (phytobezoars), milk concretions (lactobezoars), and, very
scar due to a previous surgical cesarean section and a voluminous
rarely, stones (lithobezoars). Trichobezoars form more frequently
incisional hernia in the hypogastric region (Fig. 1A). There was a
in the stomach and usually occur in individuals experiencing
green discoloration of the abdomen. On internal examination, the
trichophagia, which is a psychiatric disorder generally affecting
heart weighed 375 g and showed no signs of alterations. Macro-
children and young adults. Trichophagia, when long standing
scopically, both myocardium and heart valves revealed no signif-
and untreated, causes a condition called Rapunzel syndrome that
icant findings. There were no signs of myocardial infarction or
starts with the presence of hair in the stomach and then extends
any microscopic findings indicative of cardiac pathology. The cor-
into the small intestine.2 Because trichobezoars are caused by
onary arteries appeared pervious with mild atherosclerosis. Other
a psychiatric disorder, when psychiatric support is insufficient,
findings concerned polyvisceral congestion and pulmonary edema.
they can occur again after surgical treatment.3 Bezoars called
In the abdominal cavity, a few milliliters of yellow-citrine
pharmacobezoars are usually caused by kayexalate (sodium poly-
and turbid fluid were detected. The incisional hernia contained
styrene sulfonate), cholestyramine, antacids, and medications.4
the descending colon and part of the jejunum and the ileum. The
Lactobezoars generally occur in low–birth weight infants as a re-
bowel in the incisional hernia had fibrous adhesions but was not
sult of the concretion of milk formulas.5,6
incarcerated (Fig. 1B). The central part of the descending colon
The most common type of bezoar is the one composed of
(which was located in the sac of the hernia) presented thickened
plant material fibers, ie, a phytobezoar.
walls and a malacic area of red-grey granular appearance, in
The formation of phytobezoars is thought to be favored by
whose context was detected a voluminous, undigested fragment
a high-fiber diet. In particular, high-fiber foods such as celery,
of vegetable food (part of an artichoke) (Fig. 1, C and D). There
were no firm stools proximal to the blockage. Partially down-
stream to the site of the obstruction, another necrotic area was vis-
Manuscript received August 4, 2017; accepted October 29, 2017. ible (it was the extension of the ischemic injury of the intestinal
From the *Department of Legal and Forensic Medicine, University of Genova, wall due to the obstruction). Peritoneal serosal surfaces appeared
Genova; and †Department of Clinical Pathology, S. Croce e Carle Hospital,
Cuneo, Italy.
hyperemic and infiltrated. Colonic biopsies were taken and
The authors report no conflict of interest. stained with hematoxylin-eosin. We later performed a micro-
Reprints: Francesco Ventura, MD, PhD, Department of Legal and Forensic scopic analysis, which allowed us to observe large areas of necro-
Medicine, University of Genova, Via A. De’ Toni 12, 16132 Genova, Italy. sis and ulceration of the mucosa and submucosa of the colonic
E-mail: francesco.ventura@unige.it.
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wall, coated with fibrin and leukocytes infiltration (Fig. 2, A and B).
ISSN: 0195-7910/17/0000–0000 The analysis of the peritoneal serosal surfaces showed an acute
DOI: 10.1097/PAF.0000000000000373 peritonitis with a lymphocytic and granulocytic infiltration. The

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Caputo et al Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017

FIGURE 1. Autopsy findings. A, Incisional hernia in the hypogastric region. B, The incisional hernia contained the descending colon and part of
the jejunum and the ileum. C and D, Thickened walls and a malacic area of red-grey granular appearance in the central part of the
descending colon, in whose context was detected a voluminous, undigested fragment of vegetable food (part of an artichoke).

cause of death was therefore attributed to acute peritonitis secondary Colonic obstruction caused by a bezoar is not common, as
to intestinal occlusion caused by a colonic phytobezoar. demonstrated by the very few cases reported in the literature.14
Sang et al15 have described a case of colonic phytobezoar at the
level of the rectosigmoid junction. In this case, the cause of the be-
DISCUSSION zoar formation was attributed to the high consumption of persim-
Bezoars are a rare cause of GI obstruction. Their gastric loca- mons in a patient with a history of cerebral stroke and reduction of
tions are the most commonly described. In general, the presence intestinal motility due to the use of beta-blockers. Lee et al16 have
of the pyloric sphincter represents a mechanical barrier that pre- reported a similar case of intestinal obstruction secondary to
vents the passage of the mass of condensed material into the small rectum-sigma bezoar in a patient with no history of systemic dis-
and large intestines. It is thought that most risk factors leading to a eases. Bala et al17 reported a case of colonic obstruction by a
gastric bezoar are due to complications derived from a previous phytobezoar in a 78-year-old patient with a history of congenital
gastric surgery.13 Bezoars whose primary location is the small in- blindness and diabetes mellitus.
testine are rare, and they usually occur in patients with diverticu- In the case we describe, the phytobezoar, consisting of a large
losis, intestinal narrowing, or tumors. They mostly arise with an fibrous collection of vegetable (artichoke) residues, occluded the
intestinal occlusion because they locate themselves into the re- mid portion of the descending colon. Although a hypogastric
stricted parts of the small intestine causing phenomena of obstruc- incisional hernia had resulted in numerous fibrous adhesions,
tion. The most common site is the terminal ileum followed by the artichoke fiber bezoar was detected in an area devoid of any
the jejunum.1 GI tract kinking or strictures. Nevertheless, the presence of the

FIGURE 2. Histological analysis. A and B, Mucosa and submucosa of the colonic wall presented large areas of necrosis and ulceration,
coated with fibrin and leukocyte infiltration. H&E 4, H&E 10.

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Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017 Fatal Bowel Obstruction

hernia — with adhesive bands — hindered the normal progression and microscopic study of the GI system to formulate a correct di-
and elimination of the phytobezoar, thus favoring the onset of in- agnosis of death.
testinal occlusion. The presence of tenacious adhesions in the GI
tract distal to the site of the occlusion contributed to the onset of
mechanical intestinal obstruction. The ensuing ischemia of the
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