S3800 A Bizarre Bezoar Volvulus

Introduction: Phytobezoars are an accumulation of indigestible material from seeds or fruit pits which can lead to impaction or even obstruction. Only 0.4-4% of obstructions are caused by bezoars with the most common locations being stomach, followed by small intestine, and most rarely, colon. Herein; we present a case of a rare sunflower seed phytobezoar obstruction in the sigmoid leading to volvulus, another rare occurrence accounting for less than 5% obstructions. Patients suffering from bezoars should be closely monitored for the development of complications until resolution. Case Description/Methods: After consuming a considerable amount of sunflower seeds with the shells included, a 60-year-old man presents with left lower quadrant pain and hematochezia. Computed tomography (CT) showed a distended bowel loop measuring 6.2 cm with a transition point, consistent with sigmoid volvulus secondary to a bezoar measuring 5.5 cm. On DRE, palpable fibrous material was unable to be removed by manual disimpaction. On flexible sigmoidoscopy, a conglomeration of sunflower seed shells was visualized. The volvulus was successfully decompressed; however, despite endoscopic lavage the fibrous debris was unable to be evacuated. The patient had ongoing constipation for 5 more days despite an aggressive bowel regimen with laxatives and enemas. General surgery was consulted and planned for removal under anesthesia. Gastrografin contrast enema was administered prior to protoscopy which ultimately served to be therapeutic. The patient was able to effectively pass the bezoar before the procedure and bowel function returned. Discussion: In the presence of gastric acid, cellulose, lignin, and tannin are plant fibers that form the gluelike coagulum of phytobezoars. Patients can present with vague nonspecific symptoms such as abdominal pain, nausea, constipation, and/or rectal pain. It is important when taking history to identify recently ingested foods with associations to forming bezoars. CT is a reliable imaging modality to identify a bezoar, but endoscopy is considered the gold standard as it offers the opportunity for therapeutic interventions. Recognition of phytobezoar obstruction and prompt intervention may prevent complications including ileus, stercoral colitis, bowel ischemia or necrosis, peritonitis, and perforation. Treatment is dependent on case specifics and in uncomplicated cases conservative management with manual disimpaction or enemas is preferred. In cases with complications, more aggressive surgical management is warranted.