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\begin{document}

\title{Small-bowel obstruction due to excessive consumption of oleaster-leafed
pear (Pyrus elaeagnifolia Pall.): A retrospective study}



\author[1]{Serkan KARAISLI}%
\author[2]{Fatih Karayol}%
\affil[1]{Izmir Katip Celebi University Faculty of Medicine}%
\affil[2]{Mus State Hospital}%


\vspace{-1em}



  
  \date{May 29, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: Small-bowel obstruction (SBO) is a common emergency
worldwide and adhesions are the main cause. Oleaster-leafed pear (Pyrus
elaeagnifolia Pall.) is an endemic wild pear species in Anatolia. The
wild pear fruits are consumed for the treatment of diarrhea in
traditional medicine in Turkey. Here, we aimed to describe SBO caused by
excessive consumption of wild pear and compare clinical features of it
with those in adhesive SBO. Methods: The medical records of patients who
were followed with a diagnosis of SBO between May 2018 and September
2019 were reviewed. Patients with wild pear-related SBO (Group 1) and
patients with adhesive SBO (Group 2) were included in the study. Patient
characteristics, blood parameters and clinical features were compared.
Results: A total of 74 patients including 16 in Group 1 and 58 in group
2 were included. Amount of wild pear consumed was median 600 grammes
(range, 450-800 gr). The median age in Group 1 and Group 2 was 55 and
60.5, respectively. History of previous SBO was more common in Group 2
(p=0.032). Increased levels of WBC, CRP and BUN were significantly more
frequent in Group 2 (all p\textless{}0.05). Group 1 was associated with
a shorter duration of complaints and faster recovery (all
p\textless{}0.05). Surgical intervention was required for six patients
(10.3\%) in only Group 2. Conclusion: The potential adverse effects of
over-consumed traditional medicines should be kept in mind. Questioning
the last food consumed before the complaints start may be a clue for
food-induced SBO.%
\end{abstract}%



\sloppy


\textbf{Small-bowel obstruction due to excessive consumption of
oleaster-leafed pear (\emph{Pyrus elaeagnifolia Pall.):} A retrospective
study}

\textbf{Abstract}

Background: Small-bowel obstruction (SBO) is a common emergency
worldwide and adhesions are the main cause. Oleaster-leafed pear
(\emph{Pyrus elaeagnifolia Pall.} ) is an endemic wild pear species in
Anatolia. The wild pear fruits are consumed for the treatment of
diarrhea in traditional medicine in Turkey. Here, we aimed to describe
SBO caused by excessive consumption of wild pear and compare clinical
features of it with those in adhesive SBO.

Methods: The medical records of patients who were followed with a
diagnosis of SBO between May 2018 and September 2019 were reviewed.
Patients with wild pear-related SBO (Group 1) and patients with adhesive
SBO (Group 2) were included in the study. Patient characteristics, blood
parameters and clinical features were compared.

Results: A total of 74 patients including 16 in Group 1 and 58 in group
2 were included. Amount of wild pear consumed was median 600 grammes
(range, 450-800 gr). The median age in Group 1 and Group 2 was 55 and
60.5, respectively. History of previous SBO was more common in Group 2
(p=0.032). Increased levels of WBC, CRP and BUN were significantly more
frequent in Group 2 (all p\textless{}0.05). Group 1 was associated with
a shorter duration of complaints and faster recovery (all
p\textless{}0.05). Surgical intervention was required for six patients
(10.3\%) in only Group 2.

Conclusion: The potential adverse effects of over-consumed traditional
medicines should be kept in mind. Questioning the last food consumed
before the complaints start may be a clue for food-induced SBO.

\textbf{Keywords:} adhesive bowel obstruction; oleaster-leafed pear;
small-bowel obstruction; traditional medicine; wild fruit.

\textbf{WHAT'S KNOWN?}

\textbf{*} Small-bowel obstruction is one of the most common causes of
emergency service admission.

*Fruit-related phytobezoars are the most common reason for food-related
small bowel obstruction.

\textbf{WHAT'S NEW?}

*Wild fruits which are consumed for traditional medicine popular may
cause small bowel obstruction.

*Questioning 'the last food' consumed just before the complaints start
may give a clue about food-related small bowel obstruction.

*This study is the first which report a series of patients with
unfamiliar bowel obstruction associated with the wild fruit.

*This study is the first series describing food-induced SBO which
obstruction mechanism is not phytobezoars.

\textbf{Introduction}

Small-bowel obstruction (SBO) is one of the most common causes of
emergency service admission. Prior abdominal surgery-related adhesions
are the cause of 65-75\% of cases. Hernias, neoplasms, Crohn's disease,
bezoars, foreign bodies and intussusceptions are other etiological
causes of SBO.\textsuperscript{1, 2} Food-related SBO was described for
many fruits including citrus fruit, persimmons, orange pith, mango,
carrots, Brussels sprouts, wild banana and dried fruits. However, all
those reports described phytobezoars as the mechanism of
obstruction.\textsuperscript{3-5}

Pear \emph{(Pyrus)} is one of the most bred and consumed fruits in the
world. There are hundreds of Pyrus species but only 23 wild species were
described, all native to Europe, northern Africa and temperate regions
of Asia.\textsuperscript{6} Oleaster-leafed pear \emph{(Pyrus
elaeagnifolia Pall.)} is one of the endemic wild pear species of
Anatolia. Besides Turkey, it is grown also in south Ukraine, Albania,
Bulgaria, Greece and Romania.\textsuperscript{6} The wild pear fruits
mostly consumed by local people and also preferred especially for the
treatment of diarrhea in traditional medicine in
Turkey.\textsuperscript{7}

In our city, this oleaster-leafed pear tree grows naturally and fruits
are frequently consumed by local people during the harvest season. It
was noticed that many patients who excessively consumed this wild pear
for traditional diarrhea treatment admitted to the emergency department
with a SBO presentation during the harvest season. In the present study,
we aimed to describe this unfamiliar food-related SBO entity and compare
clinical characteristics of it with those in adhesive SBO.

\textbf{Material and Methods}

The medical records of adult patients (\textgreater{}18 years old) who
hospitalized due to SBO in Mus State Hospital, which is a rural hospital
in East Turkey, between May 2018 and September 2019 were collected
prospectively and reviewed retrospectively. Patient data were collected
from the patient files and hospital software database.

Patients with SBO due to excessive consumption of oleaster-leafed
pear\textbf{(Figure 1)} and patients with adhesive SBO were included in
the study. Patients with an incarcerated hernia, internal hernia,
primary malignant obstruction, bezoars, gallstone ileus, drug /
hypokalemia-related paralytic ileus, volvulus, intussusception, any
colonic obstruction, and early ([?] 6 weeks from index abdominal
operation) postoperative obstruction were excluded. Patients with
haematological disorders, chronic renal failure, urinary system disease,
congestive heart failure, active cancer, and those with incomplete
records were also excluded from the study. After the initial evaluation,
74 patients who met the study criteria were included. Patients were
divided into two groups as SBO due to excessive consumption of wild pear
(Group 1), and adhesive SBO (Group 2).

Patient characteristics such as age, sex, comorbid diseases, number of
previous abdominal operations and type of incisions, history of previous
intestinal obstruction; and clinical features including duration of
complaints, duration of hospital stay, duration of nasogastric tube
drainage, time of enteral feeding, duration of radiological recovery
(time until the disappearance of air-fluid levels on erect plain
radiograph), operations and presence of recurrence during the follow-up
were reviewed. In addition, blood parameters including white blood cell
(WBC) (reference range: 4500-10000/\selectlanguage{greek}μ\selectlanguage{english}L), C-reactive protein (CRP)
(reference range: 0-5 mg/dL), blood urea nitrogen (BUN) (reference
range: 8-20 mg/dL), creatinine (reference range: 0.6-1.2 mg/dL for men
and 0.5-1.1 mg/dL for women), BUN/creatinine ratio (reference range:
10-20) and potassium values (reference range: 3.5--5.1 mmol/L) were
noted at the day of admission to the emergency department in all
patients. Approximate amount of wild pear which patients in Group 1
consumed was also recorded at the first admission. Patient
characteristics and study parameters were compared between the two
groups.

All patients were evaluated in emergency service. Diagnosis of bowel
obstruction was established according to history, physical examination,
laboratory and radiological examination \textbf{(Figure 2)} of the
patients. The last meal/food before the complaints started were
questioned. In suspicion of bowel obstruction, a nasogastric tube and
urinary catheter were inserted and an enema was applied. Enteral feeding
was stopped and the intravenous fluid was administered. Patients whose
clinical evaluation was compatible with a complete obstruction underwent
emergency surgery. When partial bowel obstruction were determined,
patients were hospitalized for further examination and management.
Patients with a partial obstruction were administered intravenous fluid
and enema, and oral intake was stopped. Daily blood parameters and plain
abdominal radiographs were performed. If clinical improvement was
obtained, nasogastric and urinary catheters were removed and oral intake
was started. If there was no response to conservative treatment in the
first 72 hours or peritoneal irritation signs appeared in any time,
surgical intervention was decided. Open surgery was the preferred
approach due to lack of experience in laparoscopic adhesiolysis. The
colonoscopic examination was performed to exclude colonic obstruction if
a patient has not undergone colonoscopy in the last one year. Follow-up
of the patients continued until May 2020.

Written permission for this study was obtained from the administration
of the Mus State Hospital (Date: 04/30/2020, Decision No: 7407). Ethics
committee approval was obtained from the Non-Interventional Clinical
Studies Institutionel Review Board of Izmir K\selectlanguage{ngerman}âtip Celebi University
(Decision number: 877, Decision date: 09.17.2020) due to the absence of
a local ethics committee in Mus city. Written informed consents were
obtained from all patients. The study was performed in accordance with
the ethical standards as laid down in the 1964 Declaration of Helsinki.

Statistical analysis

Statistical Package for Social Sciences version 22.0 (IBM Corp.; Armonk,
NY, USA) was used for all statistical analyses. Variables were reflected
as the mean ± standard deviation and frequency values. The Levene test
was performed for the homogeneity of variances. The assumption of
normality was done with the Shapiro-Wilk test. Student's t-test was used
for continuous variables if the parametric test meets the prerequisites,
otherwise, Mann Whitney-U test was performed. Categorical variables were
compared by Chi-square test or Fisher's exact test. p\textless{}0.05 was
considered as statistically significant.

\textbf{Results}

A total of 74 patients including 16 in Group 1 and 58 in group 2 were
included in the study. Amount of wild pear which patients in Group 1
consumed was median 600 grammes (range, 450-800 gr). All patients in
Group 1 were admitted to the hospital between the end of August and the
end of November and that period was consistent with the harvesting
period of wild pears.

The median age in Group 1 and Group 2 was 55 (range, 23-74) and 60.5
(range, 18-93), respectively. Male to female ratio was 7 in Group 1 and
it was statistically significantly higher compared to Group 2 (p=0.01).
Comorbid diseases were more common in Group 2 and hypertension (n=15)
and diabetes mellitus (n=10) were the most seen comorbidities in study
group. Age, comorbidities and history of previous operation were
comparable between groups. History of previous SBO was significantly
higher in Group 2 (p=0.032). Patients in Group 2 had significantly
abnormal levels of WBC, CRP and BUN compared to Group 1 (all
p\textless{}0.05), however, there was no difference in levels of
creatinine, potassium and BUN/creatinine ratio between groups (all
p\textgreater{}0.05). Group 1 was associated with a shorter duration of
complaints and shorter length of hospital stay and also faster clinical
recovery (all p\textless{}0.05). Surgical intervention was required for
six patients (10.3\%) in Group 2. Four patients (6.9\%) underwent
surgery on the fourth day of admission due to the absence of clinical
improvement. Other two (3.4\%) patients developed an acute abdomen in
the second day of admission and taken into exploratory laparotomy.
Adhesiolysis in four (6.9\%), and segmental intestinal resection and
anastomosis were performed in two patients (3.4\%). Intestinal resection
and anastomosis required only in those who developed an acute abdomen.
Postoperative superficial surgical site infection and urinary tract
infection were developed in two patients (3.4\%) and in one patient
(1.7\%), respectively. Although the mean follow-up period was
significantly longer in Group 1 compared to Group 2, no recurrence
occurred. In group 2, SBO was relapsed in none of the patients who
underwent laparotomy. However, 11 patients (21.2\%) among 52 patients
conservatively managed readmitted to the hospital due to recurrence of
SBO during a median of 11-month (range, 7-22 months) follow-up. All
patients were treated conservatively again. The demographic
characteristics and clinicopathologic features of patients are
summarized in \textbf{Table 1} .

\textbf{Discussion}

The clinical presentations and severity of SBO depend on the level of
the blockage. Nausea, vomiting, abdominal cramps and distention, and the
decrease or absence of the passage of stool and flatus are the main
clinical manifestations of SBO. The more proximally obstruction site is
located, the more fastly symptoms ocur.\textsuperscript{8} For the
prediction of an adhesive SBO, history of a previous abdominal surgery
has a sensitivity and specificity of 85\% and 78\%,
respectively.\textsuperscript{9} In the present study, two patients
(2.7\%) in Group 2 denied any medical history for a possible cause of
adhesion including abdominal operation, peritonitis, endometriosis or
acute diverticulitis. On radiological examination, the level of
obstruction was the terminal ileum in these two patients, while other
patients had different levels of blockage which was possibly the
adhesion site.

Blood markers are specific in nor in the diagnosis of SBO neither in
determining the severity of the disease. In a prospective study of Cosse
et al.,\textsuperscript{10} procalcitonin with a value of above 0.57
ng/mL was found to be a potential predictor for small bowel ischemia
with a sensitivity of 83\%. Radiological methods including erect/lateral
decubitus plain radiographs, ultrasound (US) and computed tomography
(CT) are applicable to establish a diagnosis.\textsuperscript{8, 9} A
plain radiograph is considered as the first step radiological study. It
is a diagnostic tool in 50-60\% of the patients, while inconclusive or
misleading for others.\textsuperscript{1, 8, 11} The US is a reliable
tool with 90\% sensitivity in the diagnosis of SBO. The US can reveal
the presence of \textgreater{} 2.5-cm dilated small bowel loops and
decreased bowel peristalsis.\textsuperscript{1, 9} Diagnostic value of
intravenous contrast-enhanced CT is superior to plain radiograph and US.
In addition to this, CT enables to determine the severity and location
of the obstruction, possible cause for obstruction, and also to detect
potential complications such as bowel ischemia and
perforation.\textsuperscript{1, 8} Oral contrast is considered not to be
required in the diagnosis of SBO. On the other hand, oral contrast used
during conservative management is associated with less requirement of
laparotomy and shorter hospital stay.\textsuperscript{1, 12} As our
daily practice, we performed an erect plain radiograph as the first step
imaging for suspected cases. In the presence of air-fluid levels, an
abdominal CT was used in most patients in adhesive SBO group to identify
the level and severity of obstruction, and also eliminate other possible
abdominal pathologies. Due to its having onset in the last 24 hours and
the absence of description in the available literature, a routine CT was
performed for all patients in the wild pear group to understand the
mechanism of obstruction (partial/total) (paralytic/mechanic).

Conservative treatment is considered as the preferred treatment option
for adhesive SBO in the absence of acute abdomen signs or if there is no
evidence of intestinal ischemia or perforation. Approximately three out
of four SBO patients can be managed
conservatively.\textsuperscript{8}The optimal duration of conservative
treatment is still unclear. However, 72 hours is thought a critical
cutoff to review the operative option since a failed conservative
treatment exceeding 72 hours is correlated with increased risk of small
bowel resection, longer hospital stay and higher
morbidity.\textsuperscript{1, 13-15} Surgical intervention is mandatory
in case of small bowel ischemia/perforation or failure of conservative
treatment. Historically, laparotomic adhesiolysis has been the preferred
approach for adhesive SBO.\textsuperscript{1, 2} Laparoscopic
adhesiolysis had been described in recent decades, and it was associated
with a reduced risk of morbidity and in-hospital
mortality.\textsuperscript{15, 16} Recurrence of SBO occurs in 12\% of
conservatively treated patients within 1 year and 20\% of them after 5
years. That risk is 8\% within 1 year and 16\% after 5 years after
surgical treatment.\textsuperscript{17} In the adhesive SBO group, 6
(10.3\%) patients underwent surgery. Interestingly, all patients in the
wild pear group dramatically had clinical improvement on the first day
of admission. Recurrence only occurred after conservative treatment in
the adhesive SBO group. Recognition of excessive consumption of wild
pear as a predisposing factor for SBO and increased patient conscious
during hospital stay possibly played a role in preventing recurrence in
the wild pear group.

Patients in the wild pear group were considered as adhesive SBO at
admission due to their frequently having a history of previous abdominal
operation. Management of treatment was planned similar to adhesive SBO.
The mechanism of obstruction was not clear after excessive consumption
of wild pear. We evaluated patients for possible causes of obstruction.
1) At first, phytobezoar seemed to be a possible cause of obstruction
due to being food-related SBO and declaration of consuming pear seeds by
a few patients. However, all patients had a partial SBO and CT revealed
the absence of a phytobezoar in the level of obstruction. 2) Recognition
of hyperactive bowel sounds at admission eliminated the possibility of
paralytic obstruction. 3) Hypokalemia-related pseudo-obstruction was
ruled out because serum potassium levels were within or above normal
limits.

On the other hand, some other possible mechanisms we could not identify
might be playing a role. Oleaster-leafed pear might be including an
unidentified metabolite (or metabolites) which inhibiting
gastrointestinal motility by using several pathways. Psyllium is a
well-known diet fibre source and widely used against both constipation
and diarrhea\textsuperscript{.18} Mehmood et
al.\textsuperscript{18}reported a possible mechanism of the
antidiarrheal effect of psyllium husk. They thought blockage of
Ca\textsuperscript{+2} channels and activation of nitric oxide/cyclic
guanosine monophosphate pathways by undefined components might be
inhibiting gastrointestinal motility.

Traditional medicine is still preferred especially in rural regions and
countries with inadequate health service. Endemic trees and herbs
constitute the majority of medicines. Although oleaster-leafed pear
grows in a limited region including Anatolia and Balkans, 23 different
wild pear species grow in different regions
worldwide.\textsuperscript{6} Other wild pear species or fruits may have
a similar impact on the gastrointestinal system. We could not find
similar studies in the available literature. All previous studies and
case reports have described phytobezoars. Food-related SBO maybe has
been neglected or unreported entity.

There are some limitations of the present study. Firstly, this is a
retrospective study conducted in a single-center. Additionally, the
described wild pear type grows in a limited area in the world and these
results may not be applicable to other pear species. Finally, the number
of patients is inadequate to draw strong conclusions. On the other hand,
the main strength of the present study is it's being the first series
describing food-induced SBO which obstruction mechanism is not
phytobezoars.

\textbf{Conclusion}

The dose of the traditional medicines can not be regulated and
exaggerated treatment may mimic some clinical conditions. Physicians
should be aware of different manifestations of familiar diseases, such
as SBO, which may occur following endemic fruit consumption, especially
in the regions where traditional medicine popular. Questioning 'the last
food' consumed just before the complaints start may give a clue about
food-related SBO. Recognizing typical symptoms of excessive consumption
of any food may contribute physicians to plan the optimal management and
avoid unnecessary surgical interventions.

\textbf{Acknowledgments} : The authors thank Kas\selectlanguage{polish}ı\selectlanguage{english}m Co\selectlanguage{polish}ş\selectlanguage{english}kun and Bilal
Tekin for their procuring photos of the tree and fruit. There are no
conflicts of interest in connection with this paper. There is no
financial disclosure in connection with this paper.

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\textbf{Table(s)}

Table 1. The demographic characteristics and clinicopathologic features
of patients.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& & Group 1 (n=16) (Wild pear) & Group 2 (n=58) (Adhesive SBO) &
p\tabularnewline
\midrule
\endhead
Age (years) & & 52.6 \selectlanguage{ngerman}± 14.6 & 55.9 \selectlanguage{ngerman}± 18.4 &
0.504\textsuperscript{+}\tabularnewline
Sex & & & & 0.01\selectlanguage{ngerman}\textsuperscript{§}\tabularnewline
& Female & 2 (12.5\%) & 28 (48.3\%) &\tabularnewline
& Male & 14 (87.5\%) & 30 (51.7\%) &\tabularnewline
Comorbid disease & & & & 0.121\selectlanguage{ngerman}\textsuperscript{§}\tabularnewline
& Yes & 3 (18.8\%) & 23 (39.7\%) &\tabularnewline
& No & 13 (81.3\%) & 35 (60.3\%) &\tabularnewline
Number of previous abdominal operations & & 1.1 \selectlanguage{ngerman}±0.6 & 1.3 \selectlanguage{ngerman}±0.6 &
0.276\textsuperscript{++}\tabularnewline
Type of incision & & & & NA\tabularnewline
& Upper abdominal & 5 (31.3\%) & 12 (20.7\%) &\tabularnewline
& Lower abdominal & 2 (12.5\%) & 24 (41.4\%) &\tabularnewline
& Combined & 7 (43.8\%) & 22 (37.9\%) &\tabularnewline
& No operation & 2 (12.5\%) & 0 &\tabularnewline
History of previous SBO & & & & 0.032\selectlanguage{ngerman}\textsuperscript{§}\tabularnewline
& Yes & 2 (12.5\%) & 24 (41.4\%) &\tabularnewline
& No & 14 (87.5\%) & 34 (58.6\%) &\tabularnewline
WBC count & & & & \textless{}0.001\selectlanguage{ngerman}\textsuperscript{§}\tabularnewline
& Normal & 14 (87.5\%) & 14 (24.1\%) &\tabularnewline
& High & 2 (12.5\%) & 44 (75.9\%) &\tabularnewline
CRP & & & & 0.021\selectlanguage{ngerman}\textsuperscript{¶}\tabularnewline
& Normal & 8 (50\%) & 11 (19\%) &\tabularnewline
& High & 8 (50\%) & 47 (81\%) &\tabularnewline
BUN & & & & 0.016\selectlanguage{ngerman}\textsuperscript{¶}\tabularnewline
& Normal & 15 (93.8\%) & 36 (62.1\%) &\tabularnewline
& High & 1 (6.3\%) & 22 (37.9\%) &\tabularnewline
Creatinine & & & & 0.277\selectlanguage{ngerman}\textsuperscript{¶}\tabularnewline
& Normal & 15 (93.8\%) & 45 (77.6\%) &\tabularnewline
& High & 1 (6.3\%) & 13 (22.4\%) &\tabularnewline
BUN/creatinine ratio & & & & 0.384\selectlanguage{ngerman}\textsuperscript{§}\tabularnewline
& Normal & 8 (50\%) & 36 (62.1\%) &\tabularnewline
& High & 8 (50\%) & 22 (37.9\%) &\tabularnewline
Potassium & & & & 0.388\selectlanguage{ngerman}\textsuperscript{¶}\tabularnewline
& Normal & 15 (93.8\%) & 57 (98.3\%) &\tabularnewline
& High & 1 (6.3\%) & 1 (1.7\%) &\tabularnewline
Duration of complaints (hours) & & 12.9 \selectlanguage{ngerman}± 5.3 & 31.3 \selectlanguage{ngerman}± 16.1 &
\textless{}0.001\textsuperscript{++}\tabularnewline
Duration of hospital stay (days) & & 3.2 \selectlanguage{ngerman}± 0.8 & 5.1 \selectlanguage{ngerman}± 1.6 &
\textless{}0.001\textsuperscript{++}\tabularnewline
Duration of nasogastric tube drainage (days) & & 1.3 \selectlanguage{ngerman}± 0.5 & 1.9 \selectlanguage{ngerman}± 1 &
0.025\textsuperscript{++}\tabularnewline
Time of enteral feeding (days) & & 1.7 \selectlanguage{ngerman}± 0.7 & 2.5 \selectlanguage{ngerman}± 1.1 &
0.003\textsuperscript{++}\tabularnewline
Duration of radiological recovery (days) & & 2.4 \selectlanguage{ngerman}± 0.7 & 4.2 \selectlanguage{ngerman}± 1.4 &
\textless{}0.001\textsuperscript{++}\tabularnewline
Surgery & & & & 0.329\selectlanguage{ngerman}\textsuperscript{¶}\tabularnewline
& Yes & 0 & 6 (10.3\%) &\tabularnewline
& No & 16 (100\%) & 52 (89.7\%) &\tabularnewline
Follow-up (months) & & 17.2 \selectlanguage{ngerman}± 2.8 & 12.5 \selectlanguage{ngerman}± 4.4 &
0.001\textsuperscript{++}\tabularnewline
Recurrence of SBO & & & & 0.107\selectlanguage{ngerman}\textsuperscript{¶}\tabularnewline
& Yes & 0 & 11 (19\%) &\tabularnewline
& No & 16 (100\%) & 47 (81\%) &\tabularnewline
\bottomrule
\end{longtable}

Data were reflected as the mean \selectlanguage{ngerman}± standard deviation except where
otherwise indicated.

\selectlanguage{english}\textsuperscript{+}: Student t-test; \selectlanguage{english}\textsuperscript{++}: Mann-Whitney U
test, \textsuperscript{SS}: Chi-square test, \textsuperscript{P}:
Fisher's exact test.

NA: Not available; SBO: Small bowel obstruction; WBC: White blood cell;
CRP: C-reactive protein; BUN: Blood urea nitrogen.

\textbf{Figure Legends}

Figure 1 a-b: a: Tree and fruit of oleaster-leafed pear (\emph{Pyrus
elaeagnifolia Pall} .). b: Ripened fruits.

Figure 2 a-c: a: Air-fluid levels following wild pear consumption in a
patient with a history of operation due to peptic ulcer perforation 30
years ago. b: Dilated small-bowel loops and collapsed ascending colon
segment due to wild pear in a patient who had undergone laparoscopic
cholecystectomy 11 years ago. Note that wild pear seeds seen in the
stomach (arrow). c: Dilated bowel loops in a patient who have no history
of abdominal operation or peritonitis.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1a/Figure-1a}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1b/Figure-1b}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2a/Figure-2a}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2b/Figure-2b}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2c/Figure-2c}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

