Chewing of mixed betel leaves with areca nut and slaked lime (local name: “Doma Paani”) is a socially and culturally accepted common habit among Bhutanese as is in the other South East Asian countries. Intestinal obstruction due to a phytobezoar, resulting from the accumulation of betel quid, is unknown. We present a typical case of small intestinal obstruction due to phytobezoar in a 55-year-old Bhutanese woman, who had been chewing Doma Paani for a long duration. This case report highlights the importance of suspecting intestinal obstruction due to phytobezoar among betel leaves and areca nut chewers, presenting with the features of intestinal obstruction, and the importance of intervention in the form of cessation of chewing betel quid to prevent possible recurrent obstruction and malignancies such as oral and stomach cancers.

Keywords: Betel leaf; Phytobezoar; Intestinal obstruction

Bezoars are formed by the accumulation of eaten and indigestible materials such as hair, vegetables, and fruits including nuts in the intestinal lumen (1). There are different types of bezoars and among all, phytobezoar is the commonest (2). Phytobezoar is formed from undigested vegetable and fruit particles and contributes to about 2-4% of intestinal obstruction in all mechanical type of obstruction (2,3). CT (Computed tomography) scan is known to have good diagnostic yield and accuracy in diagnosing intestinal obstruction (4,5). However, in our setting the only CT scanner available is occasionally out of order. Therefore, Intestinal obstruction occurring in middle aged and elderly patients can be a diagnostic challenge in a poor resource setting like ours. Here we present a case of 55 years old lady who developed features of acute intestinal obstruction requiring exploratory laparotomy and decompression of the obstruction by extirpating the phytobezoar formed as a result of chronic betel quid chewing.

A 55-year-old, Bhutanese woman presented to the emergency room, Jigme Dorji Wangchuck National Referral Hospital, Bhutan in 2018 with abdominal pain for two days duration. The pain was colicky in nature, and associated with few episodes of vomiting. The vomitus was greenish in color. She has not passed feces for last two days. She did not undergo any abdominal surgeries. Retrospective inquiry after the surgery, she revealed that she has been chewing betel leaf, mixed with areca nuts and slaked lime for last 40 years of her life. In a day, she would chew not less than 15 Doma Paani. In the past, she didn’t have symptoms suggestive of acute or subacute intestinal obstruction.

On examination, she was ill looking with some dehydration. Her pulse rate was 110 beats per minute, and the blood pressure was 100/70 mmHg. Her abdomen was distended, with increased intensity and frequency of bowel sound. Digital rectal examination showed normal anal sphincter tone, and intact rectal mucosa with empty rectum. The routine blood evaluation of complete blood count, serum electrolytes, serum amylase, liver function tests and renal function test were all within the normal limits. An erect X-ray abdomen showed multiple air-fluid level suggestive of small intestinal obstruction [Figure 1]. An ultrasound of the abdomen showed dilated bowel loops.

Figure 1: The abdominal X ray showing air-fluid level suggestive of small intestinal obstruction in a 55-year-old Bhutanese woman who was a chronic chewer of betel leaf with areca nuts and slaked lime.

She was suspected to have intestinal obstruction, and the decision of surgical intervention conveyed to the patient and her family members.   In the meantime, nasogastric tube (NG) was inserted (drained bilious fluid of about 100 ml.) Dehydration was corrected using intravenous fluids as per the standard hospital protocol.
Informed written consent was obtained from the patient for exploratory laparotomy with possible temporary stoma creation. Under general anesthesia, a midline skin incision was made, and the peritoneal cavity opened into. There was a hard material causing complete obstruction of the ileum about 60 cm proximal to the ileo-cecal junction [Figure 2A]. An enterotomy was done on the anti-mesenteric border of the ileum over the obstructed site [Figure 2C] and delivered a phytobezoar measuring 6cm X 7cm [Figure 2B]. The rest of the intestines and the solid organs were found to be normal. The enterotomy was repaired with 3 zero vicryl in two layers of continuous first layer and lembert second layer. A drain was kept in-situ, and the abdominal walls closed in layers in the standard steps.

Her postoperative recovery was uneventful. NG tube was removed on second postoperative day.  She passed flatus on second day. Her drain was removed on the third day with minimal serous fluid drained. She was discharged on fourth postoperative day, after counselling to stop chewing betel leaves and areca nuts. She was followed up one month after the surgery and was healthy with normal bowel habits. She had stopped chewing Doma Paani.