Bezoars are uncommon findings in the gastrointestinal tract and are composed of a wide variety of materials. We report a case of a relapsing metal bezoar in a man with schizophrenia.
A 34-year-old man presented with a history of sub-acute onset of mild diffuse abdominal pain and abdominal distention. Physical examination revealed dullness to percussion in the upper and lower left quadrants. Past medical history was remarkable for epilepsy, schizophrenia and previous abdominal surgery for intestinal occlusion. Plain radiographs revealed objects of metal density contained within a dilated stomach. Celiotomy was performed revealing more than 350 metal objects inside the stomach. The patient was discharged and referred to a psychiatric facility.
Intestinal occlusion in patients with psychiatric disorders can result from rare causes such as bezoars. This report alerts surgeons to rule out bezoars in the differential diagnosis of intestinal occlusion in people with mental health problems.
Bezoars are uncommon findings in the gastrointestinal tract and are composed of a wide variety of materials. Large metal bezoars are very rare with only a few case reports till date in literature. We report a case of a metal bezoar in a man with Maniac Depressive Psychosis who had a history of ingesting Nails and screws of sizes varying from 2 cm to 15 cm for more than 1 year without causing any perforation and other acute complication.
A 24-year-old man presented with a history of mild dull aching type of abdominal pain of chronic onset and no other GI symptoms. The patient had history of passing small sized nails in the stools and intermittent melena for last 1 year. Physical examination revealed mild tenderness in Para umbilical region. Past medical history was remarkable for treatment of Maniac depressive psychosis. Plain radio graphs revealed objects of metal density contained within a dilated stomach at the level of L2–3 vertebrae in the midline. Celiotomy was performed and 27 metal nails and screws of sizes 6 cm to 15 cm and bent in various shapes were removed from inside the stomach. Post operatively patient recovery was normal and he was referred to psychiatrist.
Abdominal pain in patients with psychiatric disorders can result from rare causes such as bezoars and such bizarre metal nails without causing any acute abdominal symptoms. This report alerts surgeons to rule out bezoars in the differential diagnosis of chronic abdominal pain and melenic stools with no abdominal symptoms in patients with psychiatric health problems.
Bizarre; Metal; Bezoars; Nails and screws
Gastric outlet obstruction usually presents with non-bilious vomiting, colicky epigastric pain, loss of appetite and occasionally, upper gastrointestinal bleeding. Causes can be classified as benign or malignant, or as extra- or intraluminal. Gastrojejunostomy is a well-recognised surgical procedure performed to bypass gastric outlet obstruction. A bezoar occurs most commonly in patients with impaired gastrointestinal motility or with a history of gastric surgery. It is an intestinal concretion, which fails to pass along the alimentary canal.
A 62-year-old Asian woman with a history of gastrojejunostomy for peptic ulcer disease was admitted to hospital with epigastric pain, vomiting and dehydration. All investigations concluded gastric outlet obstruction secondary to a "stricture" at the site of gastrojejunostomy. Subsequent laparotomy revealed that the cause of the obstruction was a bezoar.
Many bezoars can be removed endoscopically, but some will require operative intervention. Once removed, emphasis must be placed upon prevention of recurrence. Surgeons must learn to recognise and classify bezoars in order to provide the most effective therapy.
A bezoar is a mass found trapped in the gastrointestinal system. The condition may be associated with pica, especially in developmentally retarded children. Clinical manifestations are usually nonspecific. Endoscopic diagnosis and removal of the foreign materials is often indicated. Occasionally, severe complications may occur. We report two cases to illustrate the clinical features and complications in these children. In the first case, a reliable history was not obtained in the developmentally delayed girl which precluded prompt diagnosis, but the grossly dilated stomach on plain abdominal radiograph gave clues to an underlying insidious mechanical obstruction of upper gastrointestinal tract. In the second case of a normal child, the unrelenting symptoms and weight loss prompt further investigations which revealed the diagnosis. Literature on pediatric bezoar is reviewed. Oesophagoduodenoscopy is the investigation of choice for diagnostic confirmation, but surgical facilities must be available to deal with acute complications.
Small bowel obstruction is rarely caused by bezoars concretions formed from undigested foreign material in the gastrointestinal tract. An important cause of bezoars is phytobezoars, formed from vegetables or fruits. A four-year-old boy presented to our emergency department with symptoms of acute intestinal obstruction. Upright plain abdominal radiography revealed multiple air fluid levels. Ultrasound showed no abnormalities, and because of worsening symptoms computed tomography of abdomen was performed. It showed intraluminal obstruction of the terminal ileum. Exploratory laparotomy revealed a phytobezoar consisting of undigested rhubarb. The mass was milked through the large bowel and out the anus. Although rare in humans, bezoars are a well-documented cause of small bowel obstruction and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction may require surgical treatment.
Bezoars usually present as a mass in the stomach. The patient often has a preceding history of some psychiatric predisposition. Presentation could be in the form of trichophagy followed by trichobezoar (swallowing of hair leading to formation of bezoar), orphytobezoar (swallowing of vegetable fibres). Rapunzel syndrome is a condition where the parent bezoar is in the stomach and a tail of the fibres or hair extends in to the jejunum. Presentation as intestinal obstruction due to a bezoar in the intestine without a parent bezoar in the stomach is rare, therefore we report it here.
A 35 year old lady tailor with a previous history of receiving treatment for depression on account of being infertile- years after her marriage, presented to the surgical emergency department with features of acute intestinal obstruction. Exploratory laparotomy and enterotomy revealed a cotton bezoar in the terminal ileum without a parent bezoar in the stomach. She was managed by resection of the affected segment of the ileum and end-to-end anastomosis of the bowel. In the postoperative period the patient gave a history of ingesting cotton threads whenever she was depressed.
Presence of cotton bezoar is rare and an intestinal bezoar in the absence of parent bezoar in the stomach is still rarer.
cotton bezoar; ileum
The differential diagnoses of acute abdomen in children include common and rare pathologies. Within this list, different types of bezoars causing gastrointestinal obstruction have been reported in the literature and different methods of management have been described. The aim of this article is to highlight a rare presentation of lactobezoars following prolonged percutaneous endoscopic gastrostomy feeding and its successful surgical management.
A 16-year-old boy was admitted to a paediatric ward with abdominal distension and high output from his permanent gastrostomy feeding tube, with drainage of bilious fluids. The clinical, radiological and endoscopical examinations were suggestive of partial duodenal obstruction with multiple bezoars in the stomach and duodenum. Gastrojejunostomy was performed after the removal of 14 bezoars. The child had an uneventful postoperative course and was discharged on the sixth postoperative day in a stable condition.
Lactobezoars should be included in the differential diagnosis of acute abdominal pain in patients with percutaneous endogastric feeding. Endoscopy is important in making the diagnosis of this surgical condition of the upper gastrointestinal tract in a child.
Bezoars are concretions of undigested material in the gastrointestinal tract, most commonly in the stomach. Duodenojejunal localization of bezoars is exceptional. We report a case of a 27-year-old woman who experienced nausea, vomiting and severe abdominal pain for one week. By palpation a mobile and sensitive mass, 15 × 15 cm, was detected, which filled the upper quadrant. Results of gastric endoscopy were normal. X-ray and ultrasonography suggested a bezoar. A laparotomy revealed that the jejunum was fissured by the trichobezoar ball. This trichobezoar mass was totally excised by intestinal resection.
To our knowledge, this is the first reported case of duodenojejunal fissuration caused by trichobezoar in an adult. Among patients with high subocclusif syndrome, duodenojejunal bezoar should remain a possibility in differential diagnosis.
Duodenojejunal flexure; intestinal partial obstruction; surgery; trichobezoar
Patients with mechanical small-bowel obstructions usually present with abdominal pain, vomiting, absolute constipation and varying degrees of abdominal distention. Causes can be classified as benign or malignant, or as extra- or intraluminal. A bezoar occurs most commonly in patients with impaired gastrointestinal motility. In edentulous older patients with abnormal food habits, it can also be an intestinal concretion that fails to pass along the alimentary canal.
Small bowel phytobezoars are rare and almost always obstructive. In a normal stomach, vegetable fibres that cannot pass through the pylorus undergo hydrolysis within the stomach, which softens them enough to go through the small bowel.
We present an unusual case of small intestinal obstruction caused by a phytobezoar in a patient who had neither a history of gastric surgery nor of intestinal pathology.
A 70-year-old Iraqi Kurdish man was hospitalized due to abdominal pain, vomiting and dehydration. Investigations concluded small intestinal obstruction. Subsequent laparotomy revealed that the cause of the obstruction was an eggplant phytobezoar.
Many types of bezoar can be removed endoscopically, but some will require operative intervention. Subsequently, prevention of any recurrence should be emphasized.
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by abdominal pain and postprandial vomiting. Causes of GOO include both benign and malignant disease. Bezoars, concretions of undigested or partially digested material in the gastrointestinal tract, are a rare entity and GOO due to duodenal bezoar is an uncommon presentation.
PRESENTATION OF CASE
We report the case of a 56-year-old woman who presented to the emergency department acutely with a 3-day history of epigastric pain, weakness and postprandial nonbilious vomiting. Initially, an upper gastrointestinal endoscopy (UGE) was performed to evaluate the cause of the GOO. A solid impacted bezoar was detected in the first portion of the duodenum with complete obstruction of the pyloric canal. In spite of multiple attempts for fragmentation using different devices, the extraction attempts failed. We administered acetylcysteine and cola per os. Abdominal computerized tomography was obtained and showed a solid mass in the duodenum. UGE was performed once more however, the mass was not suitable for fragmentation and removal. Thus, surgical treatment was decided. The bezoar was extracted via gastrotomy. The postoperative period was uneventful.
Even if a duodenal bezoar is small, because of its location it may cause GOO with abruptly clinical features. The diagnostic approach is similar to the other causes of the GOO. However, therapeutic options differ for each patient.
We should remember all the therapeutic and diagnostic options for a patient with upper gastrointestinal bezoars who present at the hospital whether or not there is a predisposing risk factor.
Bezoar; Duodenal bezoar; Endoscopy; Gastric outlet obstruction; Gastrotomy
The aim of this study was to observe the clinical features of a bezoar-induced small bowel obstruction and to investigate the role of abdominal computed tomography (CT) in establishing the diagnosis.
We retrospectively reviewed 20 cases of bezoar-induced small bowel obstruction in our hospital from 1996 to 2010.
Thirteen patients (65%) had a history of abdominal surgery. Nine patients (45%) were diagnosed with a bezoar before surgery, seven patients were diagnosed by using abdominal CT, and two patients were diagnosed with a small bowel series. Abdominal CT was performed in 15 patients, and the diagnostic accuracy was 47% (7/15). Surgery revealed ten bezoars in the jejunum and 11 in the ileum. Two patients had bezoars found concurrently in the stomach. Spontaneous removal took place in two patients. An enterotomy and bezoar extraction was performed in 15 patients. Fragmentation and milking, a small bowel resection, and a Meckel's diverticulectomy were performed in one patient each. Early operative treatment was possible (P = 0.036) once the bezoar had been diagnosed by using abdominal CT. There tended to be fewer postoperative complications in patients who were diagnosed with a bezoar by using abdominal CT, but the result was not statistically significant (P = 0.712).
A preoperative diagnosis of bezoar-induced small bowel obstruction by using clinical features was difficult. Increased use of abdominal CT led to a more accurate diagnosis and to earlier surgery for bezoar-induced small bowel obstructions, thereby reducing the rate of complications.
Bezoars; Small intestine, Intestinal obstruction; Computed tomography
A phytobezoar is the most common type of bezoar, which is a gastrointestinal mass composed of vegetable. A persimmon is a common cause of a phytobezoar. The majority of bezoars are found in the stomach, with the small intestine being the next most commonly involved site. The colon is a rare site for a bezoar. Recently, we experienced a colonic bezoar that caused colonic obstruction in a 66-year-old female patient who took persimmons regularly. The patient came to the hospital because of abdominal pain and distension. To differentiate a tumor or other problems that can cause intestinal obstruction, we performed an abdominal computed tomography scan and found an ovoid intraluminal mass with a mottled gas pattern in the distal descending colon. A large impacted bezoar was seen in the sigmoid colon, which was completely obstructed, and it was successfully removed by using colonoscopy.
Bezoars; Intestinal obstruction; Colonoscopy
A 5-year-old girl presented with a 3-day history of pain and distension of abdomen, bilious vomiting, bleeding per rectum and a hard lump in the left iliac fossa. Intussusception was clinically diagnosed. On exploratory laparotomy, trichobezoar showing cast of the stomach, duodenal C-loop and tail were extracted. The stomach cast was impacted at the distal ileum, while its tail traversed the ileum, ileocecal valve and extended up to the hepatic flexor. At the site of impaction, a large ileal perforation, covered by bezoar was present. Hence, x-ray did not reveal pneumoperitoneum. There was no evidence of trichobezoar in the stomach. Perforation was exteriorised as loop ileostomy. She was of normal intelligence. Psychological evaluation of the child was performed and a behaviour therapy was advocated. Ileostomy closure was done after 2 months. At 6 months follow-up, no recurrence was found.
AIM: To describe the clinical characteristics of patients with gastric or intestinal bezoars recently treated in our hospital.
METHODS: In this study, a retrospective chart review of consecutive patients with gastrointestinal bezoars, who were treated at the Samsun Education and Research Hospital between January 2006 and March 2011, was conducted. Data on demographic characteristics, clinical presentation, history of risk factors, diagnostic procedures, localization of bezoars, treatment interventions, and postoperative morbidity and mortality rates were collected and evaluated.
RESULTS: Forty-two patients [26 (61.9%) males and 16 (31.1%) females] with a mean ± SD (range) age of 55.8 ± 10.5 (37-74) years were enrolled in this study. Thirty-six patients (85.7%) had one or more predisposing risk factors for gastrointestinal bezoars. The most common predisposing risk factor was a history of previous gastric surgery which was identified in 18 patients (42.8%). Twenty three patients (54.8%) had multiple predisposing risk factors. Phytobezoars were identified in all patients except one who had a trichobezoar in the stomach. Non-operative endoscopic fragmentation was performed either initially or after unsuccessful medical treatment in 14 patients with gastric bezoars and was completely successful in 10 patients (71.5%). Surgery was the most frequent treatment method in our study, which was required in 28 patients (66.7%). Intestinal obstruction secondary to bezoars was the most common complication (n = 18, 42.8%) in our study.
CONCLUSION: The presence of multiple predisposing factors may create a synergistic effect in the development of bezoars.
Bezoar; Diospyrobezoars; Persimmon; Phytobezoar; Trichobezoar
Bezoars are masses, which are commonly encountered in patients after stomach surgery or in those with psychiatric problems, formed by the accumulation of intraluminal nondigestible substances that can lead to obstruction of the stomach and the small intestine. The anatomical changes in the gastrointestinal tract are known to cause bezoar formation. In the absence of an anatomical change, psychiatric disorders such as trichotillomania may lead to the formation of trichobezoars in the stomach. The so-called Rapunzel syndrome is the extension of the bezoars down to the duodenum and the jejunum, which is a rare condition. In this paper, a 13-year-old patient with trichotillomania is reported, who was admitted to our clinic with nausea, vomiting, and fatigue complaints, in whom a giant trichobezoar was identified, which completely filled the stomach and duodenum, without causing obstruction.
Rapunzel syndrome; trichobezoar; trichotillomania
Bezoars are concretions of foreign materials that impair gastrointestinal motility or cause intestinal obstruction in the stomach, small intestine or bowel of humans or animals. There are many types of them such as phyto, lacto and trichobezoars. Although bezoars are not rare, multiple giant bezoars which totally fill the stomach lumen and have extension to the small intestine (Rapunzel syndrome) are very rare. This is a case report of a young girl who had a history of trichophagia and presented with partial gastric and intestinal obstructive signs. The patient was healthy, and her physical exam was almost normal and the only positive thing in her past medical history was trichophagia from several years ago. She had a big trapped bobble in her stomach and several air-fluid levels in abdominal radiograph and was investigated with endoscopy which confirmed the diagnosis of a huge gastric trichobezoar.
Bezoars; Gastric Outlet Obstruction
Bezoars are a mass of ingested foreign materials commonly found in stomach in patients with psychiatric problems or history of gastric surgery. Bezoars are classified based on their composition. Frequently encountered are trichobezoars and phytobezoars composed of hair and fibres of fruits and vegetables, respectively. Primary small-bowel bezoars are a rarity and are essentially encountered in patients having small-bowel diseases such as diverticuli, strictures or tumours. Ileal bezoar leading to intestinal obstruction in absence of parent bezoar in stomach is very rare and so we present a case report here. The diagnosis was made on CT scan in which the cause was found to be an ileal bezoar. Surgical resection of the involved segment was performed and diagnosis confirmed on histopathological examination.
Bezoars are usually confined to the stomach which is seen in individuals with psychiatric illness like trichotillomania, trichophagia and gastric dysmotility. Long standing bezoars may extend into the small intestine leading to a condition known as Rapunzel syndrome. Diagnosis can be established by endoscopy, ultrasonography and computed tomography scan. Treatment includes improvement of general condition and removal of bezoar by laparoscopic approach or laparotomy. Psychiatric consultation is necessary to treat and prevent relapse. We report a case of Rapunzel syndrome in a 16-year-old girl with trichotillomania. She presented with history of epigastric mass for three months and recent onset of pain abdomen, vomiting and early satiety. Skiagram of abdomen was showing distended stomach and endoscopy revealed trichobezoar. At laparotomy, stomach was distended with trichobezoar and there were multiple small intestinal intussusceptions. Gastrotomy and manual reduction of intussusceptions with the removal of trichobezoar with its tail was done. Patient recovered completely after the procedure.
Rapunzel syndrome; Trichobezoar; Trichotillomania; Intussusception
Patient: Female, 30
Final Diagnosis: Phytobezoar
Symptoms: Nausea • vomiting
Clinical Procedure: —
Phytobezoars are a common type of bezoar known to accumulate in the gastrointestinal system.
A 30-year-old mentally retarded woman was operated on due to small bowel obstruction. A piece of tree root was extracted from the ileum. The patient was discharged from the hospital on postoperative day 7.
Due to difficulties in determining the nature of the bezoar preoperatively, small bowel obstruction due to a phytobezoar is not a common diagnosis. For bezoars, prevention is considered preferable to treatment.
Bezoars; General Surgery; Ileus; Mentally Disabled Persons
A 10-year-old boy presented with 9 months history of gradually worsening, recurrent postprandial upper abdominal pain, bilious vomiting and loss of weight. On examination the child was undernourished, had epigastric fullness and succusion splash was positive. Ultrasonography of the abdomen suggested a massively distended stomach, while an upper gastrointestinal contrast study showed a hugely dilated stomach along with dilated first and second parts of the duodenum with abrupt cut off at the level of third part of duodenum. Contrast enhanced CT scan of the abdomen revealed dilatation of the second part of the duodenum without any obvious abnormality of the aorta-superior mesenteric artery angle. Upper gastrointestinal endoscopy showed retained fluid and food material within a dilated stomach and second part of the duodenum; scope could not be negotiated into the third part because of an extrinsic compression. The child was diagnosed to be suffering from Wilkie’s syndrome. Exploratory laparotomy, performed when conservative management failed, revealed compression of the third part of duodenum by a shortened ligament of Trietz and dense peritoneal bands near the third part of duodenum. The duodenal obstruction was bypassed by performing duodenojejunostomy. The child had an uneventful postoperative recovery. He gained around 6.8 kilograms within next five months.
High intestinal obstruction; Superior mesenteric artery (SMA) syndrome; duodenojejunostomy
Purpose. The aim of this study was to present the computed tomography (CT) findings of bezoars that cause obstruction in the small bowel and to emphasize that some CT findings can be considered specific to some bezoar types.
Materials and Methods. The records of 39 patients who underwent preoperative abdominal CT and subsequent operation with a diagnosis of intestinal obstruction due to bezoars were retrospectively analyzed. Results. In total, 56 bezoars were surgically removed from 39 patients. Bezoars were most commonly located in the jejunum (n = 26/56, 46.4%). Sixteen (41.0%) patients had multiple bezoar locations in the gastrointestinal tract. Common CT findings in all patients were a mottled gas pattern and a focal ovoid or round intraluminal mass with regular margins and a heterogeneous internal structure. Furthermore, some CT findings were determined to be specific to bezoars caused by persimmons. Conclusions. Preoperative CT is valuable in patients admitted with signs of intestinal obstruction in geographic regions with a high bezoar prevalence. We believe that the correct diagnosis of bezoars and the identification of their number and location provide a great advantage for all physicians and surgeons. In addition, some types of bezoars have unique CT findings, and we believe that these findings may help to establish a diagnosis.
Antral web is a rare cause of gastric outlet obstruction in neonate. It is a 2-4 mm thin mucous membrane that can be found anywhere from 1 to 7 cm proximal to the pylorus. The baby was born at gestational age of 32+1 weeks with 1,880 g as 2nd baby of dizygotic twin. After birth, the baby had constant non-bilious vomiting without feeding while he didn't show abdominal distension or discoloration. The infantogram showed distended stomach with distal small bowel gas. Upper gastrointestinal series revealed that the antrum was abruptly narrowed at 1 cm proximal to pylorus. We performed laparotomy at the 10th day after birth and excised the 2 mm-thick web circumferentially. He began milk feeding after 6 days and discharged uneventfully at postoperative 35 days with corrected age of 38+4 weeks with body weight 2,420 g. The antral web should be considered in the case of non-bilious vomiting in neonate.
Gastric outlet obstruction; Antrum; Web; Vomiting
The formation of bile duct bezoars is a rare event. Its occurrence when there is no history of choledochoenteric anastomosis or duodenal diverticulum constitutes an extremely scarce finding.
We present a case of obstructive jaundice, caused by the concretion of enteric material (bezoars) in the common bile duct following choledochoduodenal fistula development. Six years after cholecystectomy, a 60-year-old female presented with abdominal pain and jaundice. Endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects in her biliary tract. The size of the obstructing objects necessitated surgical retrieval of the stones. A histological assessment of the objects revealed fibrinoid materials with some cellular debris. Post-operative T-tube cholangiography (9 days after the operation) illustrated an open bile duct without any filling defects. Surprisingly, a relatively long choledochoduodenal fistula was detected. The fistula formation was assumed to have led to the development of the bile duct bezoar.
Bezoar formation within the bile duct should be taken into consideration as a differential diagnosis, which can alter treatment modalities from surgery to less invasive methods such as more intra-ERCP efforts. Suspicions of the presence of bezoars are strengthened by the detection of a biliary enteric fistula through endoscopic retrograde cholangiopancreatography. Furthermore, patients at a higher risk of fistula formation should undergo a thorough ERCP in case there is a biliodigestive fistula having developed spontaneously.
AIM: Bezoars (BZ) are the most common foreign bodies of gastrointestinal tract. Clinical manifestations vary depending on the location of BZ from no symptoms to acute abdominal syndrome. When located in small bowel, they frequently cause small bowel obstruction (SBO). We aimed to present our experience by reviewing literature.
METHODS: Thirty-four patients with gastrointestinal BZ were presented. The data were collected from hospital records and analyzed retrospectively. Morbidity and mortality rates were statistically analyzed between the subgroups according to SBO and endoscopic or surgical treatment modalities.
RESULTS: The 34 patients had phytobezoars (PBZ). Two patients with mental retardation and trichotillomania had trichobezoars (TBZ). More than half of them (55.88%) had previous gastric surgery. Also most of them had small bowel bezoars resulting in obstruction. Surgical and endoscopic morbidity rates were 32.14% and 14.28% respectively. The total morbidity rate of this study was 29.41%. Four patients in surgically treated group died. There was no death in endoscopically treated group. The total and surgical mortality rates were 11.76% and 14.28% respectively. The differences in morbidity and mortality rates between the subgroups were not statistically significant.
CONCLUSION: BZ are commonly seen in stomach and small intestine. SBO is the most common complication. When uncomplicated, endoscopic or surgical removal can be applied easily.
Bezoars; Phytobezoar; Trichobezoar
We report the unusual case of a 45-year-old woman who presented with multiple episodes of small bowel obstruction. Initial exploratory lap-roscopy did not reveal an etiology of the obstruction. Subsequent upper endoscopy identified a non-obstructing gastric trichobezoar which could not be removed endoscopically but was not thought to be responsible for the small bowel obstruction given its location. One week postoperatively, the patient experienced recurrence of small bowel obstruction. Repeat endoscopy disclosed that the trichobezoar was no longer located in the stomach and upon repeat laparotomy was extracted from the mid-jejunum. In the following 8 months, the patient had no further episodes of small bowel obstruction. Consequently, gastric bezoars should be included in the differential diagnosis of recurrent small bowel obstruction.