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*
Abstract: A bezoar is a mass of undigested, or partially digested, material
forming in the lumen of the gastroenteric tract, causing occlusive or
subocclusive events. The most frequent types of bezoars are those com-
posed of vegetable fibers, also called phytobezoars, which, by virtue of
their high content in cellulose, hemicellulose, and lignin, remain undi-
gested in the stomach and intestines and, from there, can migrate and oc-
clude the narrowest portions of the bowel. The areas that are most
frequently affected by occlusive phenomena related to the presence of be-
zoars are the stomach and the small intestine, although colic localizations
are extremely rare. In this article, we have studied the case of a fatal colic
obstruction caused by a phytobezoar in an 84-year-old woman who was
found dead at her home. The autopsy revealed that the cause of the obstruc-
tion was a large artichoke fragment occluding the central part of the de-
scending colon. Additional histological examinations confirmed that the
death was attributable to bowel obstruction resulting in acute peritonitis.
Key Words: bowel obstruction, colonic bezoar, acute peritonitis, hernia,
sudden unexpected death
(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
Bezoars can be composed of hair (trichobezoars), vegetable
fibers (phytobezoars), milk concretions (lactobezoars), and, very
rarely, stones (lithobezoars). Trichobezoars form more frequently
in the stomach and usually occur in individuals experiencing
trichophagia, which is a psychiatric disorder generally affecting
children and young adults. Trichophagia, when long standing
and untreated, causes a condition called Rapunzel syndrome that
starts with the presence of hair in the stomach and then extends
into the small intestine.2 Because trichobezoars are caused by
a psychiatric disorder, when psychiatric support is insufficient,
they can occur again after surgical treatment.3 Bezoars called
pharmacobezoars are usually caused by kayexalate (sodium poly-
styrene sulfonate), cholestyramine, antacids, and medications.4
Lactobezoars generally occur in low–birth weight infants as a re-
sult of the concretion of milk formulas.5,6
The most common type of bezoar is the one composed of
plant material fibers, ie, a phytobezoar.
The formation of phytobezoars is thought to be favored by
a high-fiber diet. In particular, high-fiber foods such as celery,
Manuscript received August 4, 2017; accepted October 29, 2017.
From the *Department of Legal and Forensic Medicine, University of Genova,
Genova; and †Department of Clinical Pathology, S. Croce e Carle Hospital,
Cuneo, Italy.
The authors report no conflict of interest.
Reprints: Francesco Ventura, MD, PhD, Department of Legal and Forensic
Medicine, University of Genova, Via A. De’ Toni 12, 16132 Genova, Italy.
E-mail: francesco.ventura@unige.it.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/17/0000–0000
DOI: 10.1097/PAF.0000000000000373
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
pumpkins, peels, prunes, and especially persimmons are a risk
factor for bezoars formation.7
Other factors that predispose to the formation of a bezoar
include systemic diseases that cause alterations of the GI mo-
tility, such as hypothyroidism, postoperative adhesions, diabetes
mellitus, Guillain-Barré syndrome, and myotonic dystrophy. Fur-
ther contributing factors are represented by swallowing a large
amount of food without sufficient chewing such as may occur in
individuals with underlying dental problems especially the elderly,
the use of drugs that slow GI motility, and kidney failure.8–10
However, it was also suggested that a bezoar formation may occur
in the absence of any predisposing factor.11 With regard to age, the
risk of developing bezoars increases with age: in more than 70%
of cases, bezoars affect people older than 30.12
The most frequent locations are the stomach and the small in-
testine, particularly the terminal ileum and jejunum. The presence
of a bezoar in the large bowel is considered a fairly rare phenom-
enon. In this article, we present a rare, fatal case of colonic
phytobezoar in an 84-year-old woman.
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
of the body. The decedent was edentulous and had an old surgical
scar due to a previous surgical cesarean section and a voluminous
incisional hernia in the hypogastric region (Fig. 1A). There was a
green discoloration of the abdomen. On internal examination, the
heart weighed 375 g and showed no signs of alterations. Macro-
scopically, both myocardium and heart valves revealed no signif-
icant findings. There were no signs of myocardial infarction or
any microscopic findings indicative of cardiac pathology. The cor-
onary arteries appeared pervious with mild atherosclerosis. Other
findings concerned polyvisceral congestion and pulmonary edema.
In the abdominal cavity, a few milliliters of yellow-citrine
and turbid fluid were detected. The incisional hernia contained
the descending colon and part of the jejunum and the ileum. The
bowel in the incisional hernia had fibrous adhesions but was not
incarcerated (Fig. 1B). The central part of the descending colon
(which was located in the sac of the hernia) presented thickened
walls and a malacic area of red-grey granular appearance, in
whose context was detected a voluminous, undigested fragment
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-
ible (it was the extension of the ischemic injury of the intestinal
wall due to the obstruction). Peritoneal serosal surfaces appeared
hyperemic and infiltrated. Colonic biopsies were taken and
stained with hematoxylin-eosin. We later performed a micro-
scopic analysis, which allowed us to observe large areas of necro-
sis and ulceration of the mucosa and submucosa of the colonic
wall, coated with fibrin and leukocytes infiltration (Fig. 2, A and B).
The analysis of the peritoneal serosal surfaces showed an acute
peritonitis with a lymphocytic and granulocytic infiltration. The
www.amjforensicmedicine.com 1
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
to intestinal occlusion caused by a colonic phytobezoar.
DISCUSSION
Bezoars are a rare cause of GI obstruction. Their gastric loca-
tions are the most commonly described. In general, the presence
of the pyloric sphincter represents a mechanical barrier that pre-
vents the passage of the mass of condensed material into the small
and large intestines. It is thought that most risk factors leading to a
gastric bezoar are due to complications derived from a previous
gastric surgery.13 Bezoars whose primary location is the small in-
testine are rare, and they usually occur in patients with diverticu-
losis, intestinal narrowing, or tumors. They mostly arise with an
intestinal occlusion because they locate themselves into the re-
stricted parts of the small intestine causing phenomena of obstruc-
tion. The most common site is the terminal ileum followed by
the jejunum.1
Colonic obstruction caused by a bezoar is not common, as
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-
zoar formation was attributed to the high consumption of persim-
mons in a patient with a history of cerebral stroke and reduction of
intestinal motility due to the use of beta-blockers. Lee et al16 have
reported a similar case of intestinal obstruction secondary to
rectum-sigma bezoar in a patient with no history of systemic dis-
eases. Bala et al17 reported a case of colonic obstruction by a
phytobezoar in a 78-year-old patient with a history of congenital
blindness and diabetes mellitus.
In the case we describe, the phytobezoar, consisting of a large
fibrous collection of vegetable (artichoke) residues, occluded the
mid portion of the descending colon. Although a hypogastric
incisional hernia had resulted in numerous fibrous adhesions,
the artichoke fiber bezoar was detected in an area devoid of any
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.

2 www.amjforensicmedicine.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2017
hernia — with adhesive bands — hindered the normal progression
and elimination of the phytobezoar, thus favoring the onset of in-
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
gut wall in the affected GI tract was demonstrated both at gross
and microscopic examination. Necrosis of the ischemic segments
was complicated by secondary involvement of the serosal perito-
neum, with inflammation and infection, ultimately resulting in fa-
tal acute peritonitis.
The causative factors that have led to the formation of the
phytobezoar and the subsequent obstruction are not completely clear.
First, it is possible to assume that the woman, who was totally
edentulous, was experiencing some serious mastication disorder.
This would explain the ingestion of a large and almost intact arti-
choke fragment that, lacking the mechanical action of the chewing
process, failed to be chopped and could not be moistened by the
initial chemical digestion operated by salivary enzymes. Beyond
the cardiac orifice, precisely in the stomach, the vegetal fibers of
the artichoke, which are not very digestible, could not be attacked
by the degradation action of the gastric juices. The macroscopic
and microscopic investigation conducted on the gastric wall has
not detected alterations that could explain a reduction in gastric
acidity with consequent digestive disorders. Furthermore, the
pyloric sphincter and the ileocecal junction, examined at autopsy,
appeared competent and showed no signs of alterations or dilata-
tions. It is known that specific surgeries, which alter gastric motil-
ity, pyloric function, and decrease the production of hydrochloric
acid (resections, gastroenteroanastomosis, pyloroplasty, vagot-
omy), may reduce gastric emptying, causing stagnation of the
food content, thus favoring the formation of bezoars.18 According
to some authors, however, the occlusion caused by a phytobezoar
may impact19 not only the patients who have undergone surgery
on the stomach (58% of cases) but also, and in significant propor-
tions (42%), people with an intact GI tract.
Often, in fact, none of the predisposing causes can be recog-
nized, and only the intake and poor chewing of a large amount of
vegetables with high cellulose content can be considered the ori-
gin of the formation of a phytobezoar.
In this case, her medical history has not allowed the identifi-
cation of additional diseases known to favor the development of
bezoars, such as diabetes mellitus or autonomic neuropathies.
However, in an old and toothless person, it is not possible to ex-
clude the presence of digestive disorders with age-related alter-
ations of intestinal motility.
As subsequently confirmed by the results of the histological
analysis in the present case, the food fragment caused the occlu-
sive colic event, with necrosis and ulceration of the intestinal
wall, leading to acute peritonitis, which ultimately led to the
woman's death.
Although an intestinal occlusion caused by a bezoar is a rare
phenomenon, the clinical symptoms and the objective signs do not
differ from those of mechanical obstruction due to other causes.
Hence, an early diagnosis and prompt treatment are needed to pre-
vent fatal complications. This cause of death also needs to be in-
vestigated, especially in elderly, edentulous patients who have
undergone previous abdominal surgery. It is therefore clear the
importance of a complete autopsy and a thorough macroscopic
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fatal Bowel Obstruction
and microscopic study of the GI system to formulate a correct di-
agnosis of death.
REFERENCES
1. Bedioui H, Daghfous A, Ayadi M, et al. A report of 15 cases of small-bowel
obstruction secondary to phytobezoars: predisposing factors and
diagnostic difficulties. Gastroenterol Clin Biol. 2008,32(6-7):596–600.
2. Williams RS. The fascinating history of bezoars. Med J Aust. 1986;
145(11-12):613–614.
3. Altintoprak F. Gastric outlet syndrome associated with a recurrent
trichobezoar: report of a case. Turk J Gastroenterol. 2010;21(4):471–472.
4. Ashfaq A, Madura JA 2nd, Chapital AB. An unusual case of biliary bezoar
causing small bowel obstruction in a patient with ampullary diverticulum
and stapled gastroplasty. BMJ Case Rep. 2014;2014.
5. Dikicier E, Altintoprak F, Ozkan OV, et al. Intestinal obstruction due to
phytobezoars: an update. World J Clin Cases. 2015;3(8):721–726.
6. DuBose TM 5th, Southgate WM, Hill JG. Lactobezoars: a patient series
and literature review. Clin Pediatr (Phila). 2001;40(11):603–606.
7. Kement M, Ozlem N, Colak E, et al. Synergistic effect of multiple
predisposing risk factors on the development of bezoars. World J
Gastroenterol. 2012;18(9):960–964.
8. Yetim I, Ozkan OV, Semerci E, et al. Unusual cause of gastric outlet
obstruction: giant gastric trichobezoar: a case report. Cases J.
2008;1(1):399.
9. Buchholz RR, Haisten AS. Phytobezoars following gastric surgery for
duodenal ulcer. Surg Clin North Am. 1972;52(2):341–352.
10. Escamilla C, Robles-Campos R, Parrilla-Paricio P, et al. Intestinal
obstruction and bezoars. J Am Coll Surg. 1994;179(3):285–288.
11. Erzurumlu K, Malazgirt Z, Bektas A, et al. Gastrointestinal bezoars: a
retrospective analysis of 34 cases. World J Gastroenterol. 2005;11(12):
1813–1817.
12. De Bakey M, Ochsner U, de Simone M. Bezoars and concretions: a
comprehensive review of the literature with an analysis of 303 collected
cases and a presentation of 8 additional cases. Surgery. 1938;4:934–963.
13. Ertugrul I, Tardum Tardu A, Tolan K, et al. Gastric bezoar after Roux-en-Y
gastric bypass for morbid obesity: a case report. Int J Surg Case Rep. 2016;
23:112–115. doi:10.1016/j.ijscr.2016.04.008.
14. Law GW, Lin D, Thomas R. Colonic phytobezoar as a rare cause of large
bowel obstruction. BMJ Case Rep. 2015;2015: bcr2014208493. doi:
10.1136/bcr-2014-208493.
15. Yoon SS, Kim MS, Kang DY, et al. A case of successful colonoscopic
treatment of colonic obstruction caused by phytobezoar. J Korean Soc
Coloproctol. 2011;27(4):211–214.
16. Lee SJ, Chu SJ, Tsai SH. Colonic phytobezoar. Emerg Med J.
2007;24(7):518.
17. Bala M, Appelbaum L, Almogy G. Unexpected cause of large bowel
obstruction: colonic bezoar. Isr Med Assoc J. 2008;10(11):829–830.
18. Nambiar PK, Midha M, Schmitt JK. Gastric phytobezoar associated with
impaired gastric motility in a patient with spinal cord injury. J Spinal Cord
Med. 2002;25(1):43–45.
19. Lee JM, Jung SE, Lee KY. Small-bowel obstruction caused by
phytobezoar: MR imaging findings. AJR Am J Roentgenol. 2002;179(2):
538–539.
www.amjforensicmedicine.com 3