Elderly Male With Mesogastric Pain
Article Outline
[Ann Emerg Med. 2011;58:e1-e2.]
A 73-year-old man presented to the emergency department with 36 hours of continuous mesogastric pain and severe abdominal distention associated with alimentary and bilious vomiting and constipation. Physical examination was suggestive for small bowel obstruction. Laboratory test results were unremarkable. Medical history included chronic hepatopathy related to hepatitis C viral infection, arterial hypertension, and diabetes mellitus. He had undergone bilateral inguinal hernioplasty, laparotomic cholecystectomy, and repair of epigastric incisional hernia with prosthetic material. The patient was not edentulous, but used to eat quickly. Ultrasonography showed a long, mildly dilated segment of the small bowel in the left hemiabdomen containing an intraluminal mass. The lesion was about 3 cm long and cast a posterior acoustic shadow; its appearance suggested a foreign body (Figure 1). Computed tomography (CT) confirmed the presence of the mass, which did not enhance after contrast injection; distal loops were of normal caliber (Figure 2). The recovery was uneventful and the patient was discharged on the fifth postoperative day.
Figure 1.
Axial ultrasonographic image of the left abdomen.
Figure 2.
Oblique contrast-enhanced coronal reformatted CT image of the abdomen.
Diagnosis
Small bowel obstruction caused by an intact fresh grape. At laparotomy, the small bowel was dilated down to 60 cm proximal to the ileocecal valve, where an intraluminal foreign body was palpated. Intestinal loops beyond that point were collapsed (Figure 3). No other small bowel abnormalities such as congenital bands, strictures, or physiologic narrowing were observed. An intact fresh grape was extracted through an enterostomy (Figure 4).
Figure 3.
Abrupt change in caliber (arrow) between the proximal dilated bowel loops and the distal ones, which are collapsed.
Figure 4.
Foreign body extraction.
Used with permission of Giacomo Borgonovo, MD, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy.
Small bowel obstruction is a frequent cause of emergency surgery; most cases are due to adhesion (60%), hernia (15%), neoplasm (6%), and inflammation (5%).1 Ingested foreign bodies, especially a food bolus, is a rare cause of obstruction. Most obstructing food stuffs are phytobezoars2 occurring in patients receiving a diet rich in vegetable fibers; few cases caused by entire fruits have been reported. Obstruction from a grape was described by Cox and Grigg3 in 1986. In both cases, an intact grape had been ingested, passed through the pylorus, and stopped within an intestinal loop, creating a mechanical obstruction.
Foreign bodies are most commonly ingested by children, elderly with dental prosthesis, alcoholics, and psychiatric patients.1 Our subject did not fit into any of these categories; he habitually ate quickly, and this caused him to swallow the grape intact.
References
For the diagnosis and teaching points, see page e2.
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PII: S0196-0644(11)00462-8
doi:10.1016/j.annemergmed.2011.04.031
© 2011 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
