Small Bowel Obstruction by a Phytobezoar in a Patient With Previous Antrectomy and Billroth II Reconstruction.

A phytobezoar is a conglomerate of improperly digested fruit and vegetable debris, and its development is associated, amongst other factors, with previous gastric surgery. Most phytobezoars remain asymptomatic and are incidentally found during imaging or interventional procedures. However, in some patients, they can cause small bowel obstruction, which can subsequently lead to severe complications. Although the clinical findings are similar to other causes of intestinal obstruction, there are some particular diagnostic and treatment features more specific to phytobezoars. We present a case of an 85-year-old man with a history of previous antrectomy and Billroth II reconstruction who came to the emergency department with bilateral aspiration pneumonia and intestinal obstruction due to a bezoar. The CT scan showed bilateral inferior lobe pulmonary consolidation, as well as a marked dilation of the small bowel with gas-fluid levels and a transition to normal caliber in the terminal ileum, where an oval mottled-appearing mass suggesting a bezoar was present. An urgent laparotomy confirmed the diagnosis, and an enterotomy with removal of the bezoar was performed. Phytobezoars must be considered as a cause of intestinal obstruction, particularly when patients have a history of previous gastric surgery. Its radiological findings, particularly in CT scans, are specific and should be appreciated to establish the diagnosis promptly. The treatment of small bowel obstruction due to a phytobezoar requires surgery most of the time, and the surgeon must bear in mind the need to look for the existence of other bezoars in the gastrointestinal tract to prevent reoccurrence.

Mesenteric Schwannoma, Intestinal Malrotation and Ileal Diverticulum: A Unique Association.

Mesenteric schwannomas are rare benign tumors that arise in the mesentery. Ileal diverticula and intestinal malrotation in adults are rare findings, since they are usually asymptomatic. We present the case of an 86-year-old man, without any known previously known medical conditions, who was admitted in the emergency department with recurrent abdominal distension and intense pain. The radiological study suggested an intestinal malrotation. An exploratory laparotomy confirmed the intestinal malrotation with intermesenteric bands, as well as a mesenteric mass adjacent to an ileal diverticulum. Following a segmental enterectomy, the histology of the mass reported a mesenteric schwannoma. To the best of our knowledge, this is the first report of such association. We therefore present this report to showcase the diagnostic and therapeutical challenges in managing these conditions.

Os schwanomas mesentéricos são tumores benignos raros com origem nas células de Schwann do mesentério. Divertículos ileais e má-rotação intestinal em adultos são também achados raros, por serem geralmente assintomáticos. Neste artigo apresentamos o caso de um homem de 86 anos, sem antecedentes conhecidos, que recorre à urgência por um quadro de dor abdominal e distensão. O estudo imagiológico sugeria uma má rotação intestinal, pelo que se realizou uma laparotomia exploradora, onde se verificaram várias bandas intermesentéricas, bem como uma massa mesentérica adjacente a um divertículo ileal. Foi realizada lise de bandas e uma enterectomia segmentar. A avaliação anatomo-patológica mostrou tratar-se de um schwanoma mesentérico. Tanto quanto é do nosso conhecimento, este é o primeiro relato de um caso com esta associação tripla, e tem como objetivo reforçar os desafios diagnósticos e terapêuticos na abordagem destas patologias.

Wilkie's Syndrome: An Unexpected Finding.

Wilkie's syndrome is a rare pathology caused by extrinsic compression of the third part of the duodenum by the superior mesenteric artery (SMA) at its origin. The symptoms are variable and non-specific consisting of postprandial abdominal pain, nausea and vomiting, early satiety, anorexia, and weight loss. A contrast-enhanced CT scan is the standard imaging modality. Surgery is reserved for severe cases or those unresponsive to pharmacological treatment. We present a case of a 66-year-old woman with a history of prolonged postprandial abdominal pain, nausea, and substantial weight loss (30 kg in four months). Laboratory tests revealed acute renal failure with hypokalemia due to severe dehydration. She underwent an abdominal-pelvic CT scan that showed enlargement of the second and third parts of the duodenum, without an identifiable cause, followed by an upper gastrointestinal (GI) endoscopy that showed a dilated duodenum until D2 and inability of progression to D3, without mucosal abnormalities. Her MRI revealed considerable gastric and proximal duodenum distension with compression of D3 by the SMA. The patient underwent a laparoscopic duodenojejunostomy with intra-operative findings consistent with the diagnosis. The procedure and the postoperative period were uneventful, and the patient was discharged on the ninth postoperative day. Gastrografin study made at day six postop showed normal progression of the oral contrast. At the outpatient reevaluation one month postop, she remained asymptomatic and with progressive weight gain. Wilkie's syndrome is a rare form of intestinal obstruction, which is commonly disregarded. Its non-specific symptoms make it a challenging diagnosis and imply a high clinical suspicion. Among the different surgical options, duodenojejunostomy presents the best outcomes.