Rectal Pain and the Colonic Crunch Sign.

Case Report

A 31-year-old man presented to a local hospital with lower abdominal and rectal pain. He reported consuming a large bag of sunflower seeds (described as chewing and sucking unshelled seeds). The day after ingestion he noted progressive abdominal pain and difficulty passing stool. Due to the pain, he attempted a self-disimpaction with inability to clear a palpable mass, prompting him to present to the emergency room. Vital signs were stable on presentation and bedside physical examination revealed a non-tender abdomen.

Laboratory work was only significant for leukocytosis of 17,000 cells/μL. Abdominal X-ray (Figure 1) suggested rectal fecal loading. Digital rectal exam revealed a “crunchy” mass. The patient underwent flexible sigmoidoscopy with visualization of a large clump of sunflower seeds (Figure 2), but it was not possible to remove them with either the water jet or snare net. He underwent colonoscopy under general anesthesia, resulting in complete evacuation. On colonoscopy, mucosal erythema and edema was noted at site of seed impaction, which appeared secondary to irritation from the bezoar. The remainder of examined colon to cecum appeared normal, without any stricture, polyp, or mass. The patient was advised to avoid ingesting sunflower seeds and was discharged home.

Figure 1

Rectal phytobezoar shown on abdominal X-ray.

Figure 2

Sunflower seeds in the rectum shown on sigmoidoscopy.

Rectal bezoars are rare, since most food bezoars cause upper gastrointestinal obstructive symptoms. Furthermore, it is unusual to encounter rectal sunflower seed bezoars in adults. Digital rectal exam in the presence of a phytobezoar can sometimes reveal a crunchy mass of seeds at the anal verge, dubbed as the “colonic crunch” sign.

Disclosures

Author contributions: S. Mahmood procured the images, wrote the manuscript, and is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.