P2.206: "Bezoar, Be Gone: A 12-Year-Old's Meckel's Detour Through the Intestines"

Introduction: Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract, resulting from incomplete obliteration of the omphalomesenteric duct. While often asymptomatic, it can present with complications such as gastrointestinal bleeding, inflammation, and, rarely, small bowel obstruction. One unusual cause of obstruction is the formation of a phytobezoar—a concretion of indigestible plant material. This report discusses a rare case of phytobezoar-induced small bowel obstruction in a 12-year-old male with Meckel’s diverticulum, highlighting the diagnostic and management challenges.

Case Description: A 12-year-old male presented with progressively worsening abdominal pain and nausea for 24 hours. He reported no bowel movements or passage of gas during this period. On examination, he had localized mid-abdominal tenderness with decreased bowel sounds, though there were no signs of peritonitis. Initial investigations revealed leukocytosis (WBC 16.8 ×10³/μL) and dilated bowel loops on abdominal X-ray. Other laboratory tests, including inflammatory markers, urinalysis, urine drug screen, and lipase, were unremarkable.

Further imaging with computed tomography (CT) of the abdomen and pelvis identified dilated loops of small bowel with regions of edema and intraluminal debris along with a focal outpouching of the small bowel, suggestive of stasis in the setting of a distal small bowel obstruction and/or bezoar with associated possible Meckel's diverticulum. The patient was admitted to Pediatric Surgery and underwent exploratory laparotomy. He was found to have a small bowel obstruction due to obstructing phytobezoar associated with Meckel's Diverticulum. The affected bowel segment and bezoar were resected followed by primary anastomosis. He recovered uneventfully and was discharged after 48 hours inpatient.

Discussion: Symptomatic Meckel’s diverticulum is uncommon, with only 2% of cases developing complications, typically before the age of two. Presentation in older children is rare, making timely diagnosis challenging. Meckel’s diverticulum can contain ectopic gastric mucosa, leading to complications such as painless rectal bleeding. However, small bowel obstruction due to a phytobezoar is exceedingly rare, with fewer than a dozen pediatric cases reported in the literature.

Phytobezoars result from the accumulation of indigestible plant fibers and are more commonly found in the stomach. Risk factors include excessive fiber intake and altered gastrointestinal motility. Diagnosis can be difficult, as phytobezoars are often poorly visualized on CT imaging. In our case, the obstructing mass was initially suspected based on imaging findings and was definitively diagnosed intraoperatively.

Conclusion: Although Meckel’s diverticulum is frequently asymptomatic, it can lead to rare complications such as phytobezoar-induced small bowel obstruction. This case underscores the importance of maintaining a high index of suspicion in pediatric patients with unexplained small bowel obstruction, especially when advanced imaging fails to clearly identify the cause. Early surgical intervention remains the definitive treatment, ensuring favorable outcomes. Recognizing this rare entity can aid in timely diagnosis and management, preventing significant morbidity.