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.

Figure 2: Intra-operative images of a 55-year-old Bhutanese woman with small intestinal obstruction due to a phytobezoar (A) external appearance of the phytobezoar, (B) Phytobezoar being extirpated from the small intestine, and (C) image of small intestine after removal of the phytobezoar showing a vertical incision on the anti-mesenteric side.

Small bowel phytobezoar causing intestinal obstruction is uncommon and a rare entity [6].  Phytobezoar are formed from undigested vegetable and fruit particles and contributes to about 2-4% of intestinal obstruction in all mechanical type of obstruction [2,3].

The factors that causes development of phytobezoar are thought to be conditions like gastric motility disorder, gastrectomy, gastro-enterostomy and excessive consuming of diets rich in fibers [7]. The clinical symptoms are dependent on the type and location of the phytobezoar in the intestinal tract which can range from dyspeptic symptoms and gastric outlet obstruction with bleeding if located in the stomach and intestinal obstruction if located in the small bowel [6]. Primary small bowel phytobezoars almost always present as small bowel obstruction and usually impacts the narrowest part of the intestine [2].

Plain x-ray abdomen usually shows the features of obstruction but cannot detect the bezoar [2]. Abdominal CT scan is the choice of investigation in the case of suspected phytobezoar and it has a diagnostic accuracy of 65-100% [5,7].  It is characterized by presence of well-defined intraluminal mass with a mottled gas pattern [3]. Ultrasonogram usage in a diagnosis of bezoar is shadowed with problems such as operator dependent and poor delineation due to obscurement by the gas in dilated bowel loop [8].

Treatment of bezoar can depend on their size and location. Expectant management by natural excretion in small bezoars and removal by endoscopy, jejunotomy, ileotomy and gastrotomy are all possible [5]. However, surgical intervention is usually required in most of the cases [9].

Doma Paani is a combination of areca nut and slacked lime wrapped around a betel leaf and it is rich in fiber content. It is traditionally chewed by many in Bhutan with a prevalence of 45.5% with more female preponderance [10]. The patient in our case had consumed Doma Paani for 40 years and she chewed it not less than 15 pieces every day. Although the features of intestinal obstruction are characterized by classic clinical symptoms and signs, non-availability of advanced imaging modality like CT scan can be a challenging and lead to a diagnostic dilemma. The dentition in the people with chronic Doma Paani chewer are often poor and damaged. This would also contribute to the formation of phytobezoar which is one cause highlighted in many case reports [2,3,6].

With almost 45.5% of Bhutanese population chewing Doma Paani habitually, physicians attending emergency clinic should routinely ask about the Doma Paani chewing habits in a patient with suspected gastrointestinal obstruction. Although X-ray abdomen can provide a clue on obstruction, CT scan is required for a definite conclusion. In a resource poor setting only the suspicion and exploration to ascertain the cause is a choice of treatment.

We would like to thank Dr. Sangay Tshering, (Obstetrician & Gynecologist), Dr. Gyan Prasad Bajgai, (Oral Medicine Specialist) and all other staff of OT, ER and ward inclusive of doctors, specialists and nursing personnel for their hard work and contribution towards the success of management of this patient and in publication of this case report.

None

1. Bingham JR, Causey MW, Haque MI. Phytobezoar within Meckel’s Diverticulum: An Unusual Cause of Intestinal Obstruction. Am Surg. 2014;80:e94-e96.
2. Razavianzadeh N, Foroutan B, Honarvar F, et al. Small Bowel Obstruction Attributable to Phytobezoar. Oxford Med Case Reports. 2016;2016:305-308.
3. Salemis NS, Panagiotopoulos N, Sdoukos N, et al. Acute Surgical Abdomen Due to Phytobezoar-Induced Ileal Obstruction. J Emerg Med. 2013;44:e21-e23.
4. Ho TW, Koh DC. Small-bowel Obstruction Secondary to Bezoar Impaction: A Diagnostic Dilemma. World J Surg. 2007;31:1072-1078.
5. Oh SH, Namgung H, Park MH, et al. Coloproctology Bezoar-induced Small Bowel Obstruction Coloproctology. Ann Coloproctol. 2012;28:89-93.
6. Bouali M, Ballati A, El A, Elhattabi K, et al. Phytobezoar : An Unusual Cause of Small Bowel Obstruction. Ann Med Surg. 2021;62:323-325.
7. Bedioui H, Daghfous A, Ayadi M, et al. A Report of 15 Cases of Small-bowel Obstruction Secondary to Phytobezoars: Predisposing Factors and Diagnostic Difficulties. Gastroenterol Clin Biol. 2008;32:596-600.
8. Espinoza González R. Gastrointestinal Bezoars. Rev Med Chil. 2016;144:1073-1077.
9. Kim JH, Ha HK, Sohn MJ, et al. CT Findings of Phytobezoar Associated with Small Bowel Obstruction. Eur Radiol. 2003;13:299-304.
10. Wangdi K, Jamtsho T. Prevalence and Correlates of Betel Quid Chewing among Bhutanese Adults. Subst Use Misuse. 2020;55:1443-1449.

Corresponding author: Gyan Prasad Bajgai, Oral Medicine Specialist, JDWNRH, Bhutan.