Photo Rounds

Obstipation

A 64-year-old woman came into the emergency department complaining of constipation and rectal pain. She indicated that in an attempt to promote her overall health, she’d recently begun experimenting with healthy alternatives to her regular diet. To relieve her constipation, she’d tried numerous over-the-counter remedies and had even gone to an urgent care clinic, where a trial of manual disimpaction had been unsuccessful.

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Computed tomography (CT) imaging revealed a proctophytobezoar. On follow-up questioning, the patient recalled consuming approximately 10 ounces of cooked quinoa, a nutritious, gluten-free, high-protein seed, just prior to the onset of her constipation.

A bezoar is a mass of poorly digested material that forms within the gastrointestinal tract—usually in the stomach—and less commonly in the small or large intestine. Trichobezoars (hair), lactobezoars (milk curd), phytobezoars (plant fiber), medication bezoars, and lithobezoars (small stones, pebbles, or gravel) are named after their contents.

Fecal impaction due to phytobezoars primarily composed of seeds has been associated with prickly pears, watermelons, sunflowers, pumpkins, pomegranates, and sesame seeds. This patient’s experience adds quinoa seeds to this list.

Treatment begins with a pharmacologic approach. When that fails, it’s time to perform a manual fragmentation and extraction of the fecal mass. Once fragmentation and partial expulsion has been achieved, one can then try a lubricating mineral oil enema, bisacodyl suppository, or rectal lavage. If the impaction extends beyond the reach of the fingers, sigmoidoscopic visualization and lavage are indicated.

Since conservative and comprehensive management to improve this patient’s condition failed, she was taken to the operating room for a proctosigmoidoscopic disimpaction. The patient made an uneventful recovery and was discharged on hospital Day 3.

Adapted from: Pelletier JF, Higgins GL, Haydar SA. Photo Rounds: Obstipation unresponsive to usual therapeutic maneuvers. J Fam Pract. 2012;61:353-355.

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