Cocoa Seeds as a Phytobezoar Causing Intestinal Obstruction in a Ghanaian Child: A Case Report

Phytobezoars are indigestible organic matter that forms organized masses in the gastrointestinal tract. Seeds reported causing bezoars include sunflower seeds, watermelon seeds, and wild banana seeds. Cocoa seeds causing bezoar have not been reported. The seeds tend to have an outer shell that cannot be digested by human digestive enzymes. Cocoa seed has a shell made of pectic polysaccharide, hemicellulose, and cellulose, which cannot be digested by human digestive enzymes. Accumulation of these seeds and fibers swallowed or chewed in some parts of the small intestine, the colon, and rectum, with fluid absorption in these parts of the tract, forms hard bezoars in the tract and can sometimes lead to intestinal obstruction. Reported cases of seed phytobezoar follow the geographical distribution of the seed or fruit, the dietary habits of the people, and the seasonal pattern of maturity of the seeds and fruit. Patients present with non-specific abdominal symptoms. Intestinal obstruction is a rare complication, and if present, the patient will present with associated constipation, vomiting, and abdominal distension. Known predisposing factors to bezoar formation from phytobezoars include previous gastric surgery, neuropsychiatric disorder, and endocrinopathies, even though the majority will have no risk factors. Diagnosing involves a good history and examination. Anoscopy or colonoscopy is used in selected cases to identify gastrointestinal masses as an underlying cause of bezoar formation. CT scan is the gold standard, and other imaging, like abdominal X-ray and ultrasound, may be useful in diagnosing and locating the bezoar and complications in a limited resource environment. Management includes manual evacuation under anesthesia if the bezoar is in the rectum. Targeted deimpaction with enzymes may be considered in some cases. Bezoars higher up in the tract or with complications of ischemia or perforation will require surgery or endoscopy. We present a rare case of cocoa seeds bezoar causing intestinal obstruction in a six-year-old child from a rural town in the Asante Region of Ghana, presenting to Komfo Anokye Teaching Hospital in Ghana, West Africa.