Rutgers Health/Trinitas Regional Medical Center Elizabeth, New Jersey
Introduction: Bezoars are solid masses of indigestible materials that accumulate in the gastrointestinal tract (GIT). They are classified according to their content and sites in the GIT. We present a case of large bowel partial obstruction secondary to bezoar, attributable to chronic opioid use.
Case Description/Methods: A 65-year-old male with a history of hypertension, occasional constipation with unremarkable colonoscopy two years ago, spinal stenosis with fully functioning activity on chronic opioid use for 10 years, presented with worsening abdominal pain and distension with small bowel movements for five days. He reported nausea with no vomiting. Physical exam showed normal vital signs and distended soft abdomen with no tenderness or guarding. CT abdomen showed 10 x 6 cm partially obstructing bezoar in the proximal transverse colon, with decompressed distal colon, and with no small bowel obstruction [Figure 1]. He was started on different laxatives and enemas for 3 days with no improvement. Colonoscopy showed a large obstructing stoolball [Figure 1] that was not getting fragmented by polypectomy snares, tripod forceps, or water piks. Surgical removal of the bezoar was then performed with primary anastomosis. He remained stable and was discharged on Senna with instructions for a follow-up colonoscopy, and to avoid opioids.
Discussion: Bezoars are uncommon causes of GIT obstruction. They are classified according to their content into phytobezoars (indigestible food particles), trichobezoars (hair and food particles), and pharmacobezoars (concretions of different medications). They commonly occur in the stomach, however; they can occur in any part of the GIT. Bezoars' common risk factors are altered GIT anatomy or motility such as post abdominal surgery, diabetic gastropathy, Guillain-Barre syndrome, bedridden state, and medications with intestinal hypokinetic effects. Chronic opioid use is the culprit risk factor in our patient. GIT obstruction is a common complication of bezoars although it rarely occurs in the colon. A plain radiograph is usually the first diagnostic modality, however; a CT abdomen is often needed. Management varies from medical to endoscopic or surgical according to the bezoar's size and the associated complications. Our patient was treated surgically after failed medical and colonoscopic treatment. This raises the importance of the concomitant use of stimulant laxatives with opioids and avoiding chronic opioid use in unnecessary conditions to prevent such complications.
