Winning Abstracts from the 2012 Medical Student Abstract Competition: Xylobezoar (Paper Bezoar) in the Sigmoid Colon Masquerading as Diverticulitis
Author: Sophia Nguyen, BA - University of Colorado School of Medicine, Class of 2012
Introduction: Bezoars are accumulations of indigestible material such as vegetable matter, hair or medications in the gastrointestinal tract. These concretions are most frequently found in the stomach and can cause serious medical problems such as bowel obstruction, impaction and perforation.
Case Presentation: A 41-year-old female with a history of bipolar disorder and iron deficiency anemia presented to the emergency department with 2 days of severe stabbing left lower quadrant (LLQ) abdominal pain radiating to the left groin. The pain was unchanged with food intake or position. She had not had a bowel movement (BM) in 3 days. Her medical history revealed occasional pica, a previous ectopic pregnancy and regular menstruation without menorrhagia. She smoked tobacco and was on parole for previous cocaine use. On physical exam, her vital signs were normal and she had LLQ abdominal tenderness but no peritoneal signs. An initial work-up revealed a WBC 14K/uL, hematocrit 31%, MCV 78fl, ferritin 69g/L and iron saturation 3%. Urinalysis, urine hCG and comprehensive metabolic panel were normal. A CT KUB showed a strictured segment of the sigmoid colon with mild pericolonic inflammatory fat stranding around the descending colon seemingly most consistent with colitis. Intravenous metronidazole and ampicillin-sulbactam were initiated for treatment of diverticulitis.
Due to continued constipation and concern for a stricture and mechanical obstruction, a flexible sigmoidoscopy was scheduled. Upon re-interviewing the patient, she admitted to recent consumption of paper in the amount of 2 novels. Subsequent sigmoidoscopy revealed a large bezoar composed of typing paper with visible printed words in the sigmoid colon causing complete obstruction. Neither snare nor roth net were able to remove the bezoar. This area was flushed with 1.5 L of tap water which allowed stool to pass and revealed underlying mucosal ulceration and large diverticula. With daily enemas and a liquid diet, the patient was able to pass the bezoar and resumed normal BMs.
Discussion: Given the inherent ability of bezoars to mimic various gastrointestinal maladies, clinicians should have a high index of suspicion when evaluating a patient with abdominal pain, a history of pica and underlying psychiatric illness. Most commonly, bezoars are diagnosed by endoscopy and are composed of hair. Only few cases of paper bezoars causing colonic ischemia have been reported and these have been diagnosed by laparotomy. Thus, this is a rare case of a colonic xylobezoar diagnosed and treated via flexible sigmoidoscopy. Furthermore, this patient likely had iron deficiency anemia caused by her mucosal ulceration and diverticula, thereby escalating her paper craving. Early recognition could help shorten hospitalization time, allow for diagnostic and therapeutic endoscopy as opposed to surgery and decrease complications associated with bezoars.