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Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.104 n.5 Madrid May. 2012

http://dx.doi.org/10.4321/S1130-01082012000500008 

PICTURES IN DIGESTIVE PATHOLOGY

 

Rectal ulcer secondary to a fecal impaction due to pomegranate seed bezoar

Úlcera rectal secundaria a fecaloma por semillas de granada

 

 

Cristina Martínez-Pascual, Alejandro Martínez-Caselles, Gonzalo Antón-Ródenas, Elena Navarro-Noguera, Antonio Sánchez-Torres, Bartolomé García-Pérez and Luis Fernando Carballo-Álvarez

Department of Digestive Disease. Hospital Universitario Virgen de la Arrixaca. Murcia, Spain

 

 

Introduction

Fecal impaction is a mass of hardened and compacted stools that the patient can not evacuate spontaneously. It usually occurs in elderly patients disabled or institutionalized but cases have also been reported secondary to foreign bodies, bezoars, etc. The usual symptom is constipation, but overflow diarrhea can also occur. The diagnosis of fecal impaction is made with digital rectal examination. Most of the time, it can be removed manually.

 

Case report

We present the case of a 44-year-old male patient. His past medical history included only CMV colitis two years earlier with a good response to treatment with ganciclovir.

The patient was admitted as an emergency with symptoms of diarrhea over the past 48 hours, with strands of blood in the stool, and no other associated symptoms. The blood test including blood count, renal and liver function was normal, with slight increase of C-reactive protein (1.6 mg/dL). The abdominal radiograph showed no abnormalities.

When the patient was transferred to our department, he reported that he has eaten two pomegranates in the last 5 days. Rectal examination revealed a hard fecal mass that could be removed by manual disimpaction. The feces contained multiple pomegranate seeds.

Ileocolonoscopy showed a circumferential rectal ulcer (Fig. 1), coated with a fibrin exudate (Fig. 2) and located 2 cm from the dentate line. In addition, some serpiginous ulcerations extended to the first rectal valve (Fig. 3). A biopsy of the ulcer did not show histological features of inflammatory bowel disease and excluded CMV colitis, using immunohistochemistry and CMV PCR.

 

 

 

 

After manual disimpaction, the patient remained asymptomatic. A diagnosis of overflow diarrhea secondary to fecal impaction due to pomegranate seed bezoar and secondary traumatic rectal ulcer was made.

 

Discussion

Several cases of fecal impaction due to seed bezoars have been described in the literature, mainly in children. Etian et al. published the largest series of cases of fecal impaction due to seed bezoars in both children (1) and adults (2). They undertook a retrospective review of patients with a diagnosis of fecal impaction at Western Galilee Hospital of Israel. Their study revealed a high percentage of fecal impaction due to seed bezoars, 89% in children and 55% in adults. They attributed these high percentages to the eating habits of the Middle East.

In order of frequency seed bezoars are composed of watermelon seeds (1,2), prickly pears seeds (1,2), sunflower seeds (1,2,3) and pumpkin seeds (1,2,4). Only one case of fecal impaction due to pomegranate seed bezoar has been described in the literature (2). Other anecdotal cases are caused by the popcorn kernels (2), the poppy seeds (5) and the grape seeds (6). In most of the reported cases the treatment included disimpaction and irrigation of the rectal content under anesthesia.

 

References

1. Eitan A, Katz IM, Sweed Y, Bickel A. Fecal impaction in children: report of 53 cases of rectal seed bezoars. J Pediatr Surg 2007;42(6):1114-7.         [ Links ]

2. Eitan A, Bickel A, Katz IM. Fecal impaction in adults: report of 30 cases of seed bezoars in the rectum. Dis Colon Rectum 2006;49(11):1768-71.         [ Links ]

3. Purcell L, Gremse DA. Sunflower seed bezoar leading to fecal impaction. South Med J 1995;88(1):87-8.         [ Links ]

4. Mirza MS, Al-Wahibi K, Baloch S, Al-Qadhi H Rectal bezoars due to pumpkin seeds. Trop Doct 2009;39(1):54-5.         [ Links ]

5. Rejmanowski T. Fecal impaction of inguinal hernia caused by consumption of poppy seeds. Pediatr Pol 1966;41(5):587-9.         [ Links ]

6. Burnikel Rh, Sprecher Hc. Fecal impaction; report of a case due to wild grape seeds and elderberry stems. Am J Dig Dis 1952;19(6):191-2.         [ Links ]

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