Giant Colonic Lithobezoar: A Rare Case Report.

Bezoar is defined as the accumulation of undigested foreign bodies or nutrients in the gastrointestinal tract. Lithobezoar, the accumulation of stones in the digestive tract, is commonly seen in the stomach. We report a case of giant colonic lithobezoar in a child. Copyright:

INTRODUCTION

Colonic lithobezoar is rare in children more so in adults. It is commonly associated with a history of pica. Pica is an eating disorder characterized by persistent ingestion of nonnutritive substances. Colonic lithobezoar usually presents with mechanical large bowel obstruction.[12345678]

CASE REPORT

A 5-year-old male child presented to us with a history of diarrhea associated with passing of stones in the stools for 3 days. The child did not have any vomiting, pain abdomen, or fever. The child was taken to a local doctor, where abdominal radiography was done, suggestive of giant colonic lithobezoar [Figure 1a] and hence referred to our institute. On examination, the child was stable and cooperative, abdomen was soft without distention or tenderness, and per-rectal examination revealed crenated stony feel. He was admitted and tap water enemas twice daily were started. Subsequently, he passed stones in the stools of sizes varying from 5 mm to 2.4 cm following enemas [Figures 1b and 2a]. The child was observed closely in the hospital till abdominal radiography revealed clearing of the stones [Figure 2b]. Meanwhile, on evaluation, the baby's hemoglobin was found to be 7 gm%; hence, nutritionist's opinion was taken and started on oral hematinics. The child's psychiatric evaluation was found to be normal. He was followed with daily tap water enemas and was discharged after 4 days uneventfully and successfully without requiring any anesthesia or surgical interventions.

Figure 1

(a) Plain abdominal radiography – giant colonic lithobezoar and (b) plain abdominal radiography – after partial clearance of lithobezoar

Figure 2

(a) Manually evacuated as well as spontaneously passed lithobezoar, (b) plain abdominal radiography – after clearing of giant colonic lithobezoar

DISCUSSION

Pica is persistent eating of nonnutritive substances and is common in children. The cause of pica is unknown, but multifactorial etiology has been suggested. Iron deficiency anemia and underlying psychiatric illness have been suggested as one of the etiologies. Bezoars may be composed of hair (trichobezoars), vegetable matter (phytobezoars), milk curds (lactobezoars), sand bezoar, and very rarely, stones (lithobezoars).[12345678]

Clinically, these children often present with signs and symptoms of mechanical bowel obstruction. A palpable abdominal mass occasionally found. On rectal examination, the presence of the “colonic crunch sign” can increase the suspicion of bezoar obstruction.[23456]

The scattered radiopacities on routine abdominal radiography are typical of lithobezoar and called as “corn on the cob appearance” [Figure 1a].[12345678]

As per our literature search, we found seven cases which were managed by manual evacuation of the stones under general anesthesia.[1234567] Aihole reported two additional cases in September 2018, of colonic lithobezoar where both cases were managed successfully by daily tap water enemas without requiring general anesthesia or any surgical interventions [Table 1].[8]

Table 1

Colonic lithobezoar in children overview of literature

Study	Age	Gender	Signs and symptoms	Physical examination	Radiology	LAB	PICA	Treatement
Numanoğlu and Tatli[1]	4	M	C, abdominal distension	Irregular mass at palpation	X ray	HCT:21, 1	NA	Anal dilatation, extraction of stones
Narayan et al.[2]	9	M	C, AP	Prickly mass per rectum	X ray	N/A	+	Laxative+ rectal flush out
Mohammad[3]	8	M	Bilious vomiting, abdominal distension	Moderate distension, PM no features of peritonitis	X ray	N/A	+	Anal dilatation, extraction of stones
Sheikh et al.[4]	9	M	C, AP, failure to thrive, painful defecation	Moderate distension, PM, no features of peritonitis	X ray	N/A	+	Anal dilatation, extraction of stones
Tokar et al.[5]	6	F	C, AP	PM	X ray	N/A	+	Anal dilatation, extraction of stones
Vijayambika[6]	6	M	C, AP	Poorly localized tenderness	X ray	N/A	+	Laxative and rectal flush out
Senol M et al.[7]	7	F	C, AP	Mild tenderness	X ray	HCT22.5%	+	Anal dilatation, extraction of stones GA
Jayalaxmi S Aihole[8]	5	M	C, painful defecation	Poorly localized tenderness	X ray	Hb-7	+	Daily enemas
Jayalaxmi S Aihole[8]	7	M	C, painful defecation	Poorly localised tenderness	Xray	Hb-7	+	Daily enemas

C: Constipation, AP: Abdominal pain, PM: Palpable mass, GA: General anaesthesia

A single case of giant colonic lithobezoar has been reported by Sheikh et al. in a 9-year-old male child, managed by manual evacuation under general anesthesia.[6] Similarly, in our institute, a case of giant colonic lithobezoar in a 5-year-old male who presented to us with a history of diarrhea and passing of stones in the stools was managed expectantly by regular enemas and nutritional support under close observation, in the hospital.

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Conflicts of interest

There are no conflicts of interest.