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.8 For the
prediction of an adhesive SBO, history of a previous abdominal surgery
has a sensitivity and specificity of 85% and 78%,
respectively.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.,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.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.1, 8, 11 The US is a reliable
tool with 90% sensitivity in the diagnosis of SBO. The US can reveal
the presence of > 2.5-cm dilated small bowel loops and
decreased bowel peristalsis.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.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.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.8The 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.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.1, 2 Laparoscopic adhesiolysis had been described
in recent decades, and it was associated with a reduced risk of
morbidity and in-hospital mortality.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.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.18 Mehmood et al.18reported a possible mechanism of the antidiarrheal effect of psyllium
husk. They thought blockage of Ca+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.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.