Pediatric Annals

CME Article 

Agitation and Decreased Oral Intake in an Adolescent with Autism

Prita H. Mohanty, MD; Megan Gabel, MD

Abstract

CME Educational Objectives

  1. Understand that in developmentally delayed, and autistic children, gastrointestinal conditions can present typically or atypically as non-gastrointestinal manifestations, including behavioral changes and problem behaviors.

  2. Maintain an index of suspicion for bezoars in cases of bowel obstruction in these children.

  3. Review the presentation and evaluation of children with bezoars.

A 14-year-old boy with autism was referred to the emergency department because of a 3-week history of decreasing oral intake and a 20-lb unintentional weight loss. History of chewing on nonfood items such as erasers, rubber items and toilet plungers was elicited.

There was no history of fever, vomiting, diarrhea, or constipation. There were no sick contacts and no significant recent travel.

His past surgical history and family history were unremarkable. Of note on social history, this young man was living with his grandmother and siblings. His home environment was disorganized and chaotic.

When examined, he was nonverbal, withdrawn, and agitated. His weight was 90 kg (> 95th percentile), height was 173 cm (75th percentile), and body mass index was 30 kg/m2. His vital signs were normal. The abdomen was soft and not tender.

Plain abdominal radiographs showed signs of partial intestinal obstruction with intraintestinal foreign bodies.

Abdominal computed tomography showed focally dilated loops of small bowel with intraluminal foreign bodies, possibly bezoars (Figure 1). Radio-opaque densities were also noted in the pyloric region and transverse colon.

Abstract

CME Educational Objectives

  1. Understand that in developmentally delayed, and autistic children, gastrointestinal conditions can present typically or atypically as non-gastrointestinal manifestations, including behavioral changes and problem behaviors.

  2. Maintain an index of suspicion for bezoars in cases of bowel obstruction in these children.

  3. Review the presentation and evaluation of children with bezoars.

A 14-year-old boy with autism was referred to the emergency department because of a 3-week history of decreasing oral intake and a 20-lb unintentional weight loss. History of chewing on nonfood items such as erasers, rubber items and toilet plungers was elicited.

There was no history of fever, vomiting, diarrhea, or constipation. There were no sick contacts and no significant recent travel.

His past surgical history and family history were unremarkable. Of note on social history, this young man was living with his grandmother and siblings. His home environment was disorganized and chaotic.

When examined, he was nonverbal, withdrawn, and agitated. His weight was 90 kg (> 95th percentile), height was 173 cm (75th percentile), and body mass index was 30 kg/m2. His vital signs were normal. The abdomen was soft and not tender.

Plain abdominal radiographs showed signs of partial intestinal obstruction with intraintestinal foreign bodies.

Abdominal computed tomography showed focally dilated loops of small bowel with intraluminal foreign bodies, possibly bezoars (Figure 1). Radio-opaque densities were also noted in the pyloric region and transverse colon.

A 14-year-old boy with autism was referred to the emergency department because of a 3-week history of decreasing oral intake and a 20-lb unintentional weight loss. History of chewing on nonfood items such as erasers, rubber items and toilet plungers was elicited.

There was no history of fever, vomiting, diarrhea, or constipation. There were no sick contacts and no significant recent travel.

His past surgical history and family history were unremarkable. Of note on social history, this young man was living with his grandmother and siblings. His home environment was disorganized and chaotic.

When examined, he was nonverbal, withdrawn, and agitated. His weight was 90 kg (> 95th percentile), height was 173 cm (75th percentile), and body mass index was 30 kg/m2. His vital signs were normal. The abdomen was soft and not tender.

Plain abdominal radiographs showed signs of partial intestinal obstruction with intraintestinal foreign bodies.

Abdominal computed tomography showed focally dilated loops of small bowel with intraluminal foreign bodies, possibly bezoars (Figure 1). Radio-opaque densities were also noted in the pyloric region and transverse colon.

Computed tomography showing distended small bowel loops extending from adjacent to the splenic flexure through the left lower quadrant, (left panel) with numerous linear intraluminal radio-opaque foreign bodies and fluid (right panel).All images courtesy of Prita H. Mohanty, MD. Reprinted with permission.

Figure 1. Computed tomography showing distended small bowel loops extending from adjacent to the splenic flexure through the left lower quadrant, (left panel) with numerous linear intraluminal radio-opaque foreign bodies and fluid (right panel).All images courtesy of Prita H. Mohanty, MD. Reprinted with permission.

The patient underwent laparotomy and a large mass of impacted foreign material was found extending from the proximal jejunum to the ileum. The ileocecal valve was approximately 20 cm distal to the mass. The small bowel contained a total of 10 perforations of varying sizes covered by omentum and scattered throughout the jejunum and ileum. Surgery included two segmental enterectomies measuring 20 cm and 150 cm in length, enteroenterostomy, and omentectomy. The resected pathological specimen contained a large synthetic bezoar composed of an aggregate of coiled cylindrical material consistent with wires. Enmeshed with the wires were paper, cloth, rubber-like material, and foam. Histologic sections of the resected bowel demonstrated multiple perforations associated with transmural necrosis (Figure 2).

(A, B, C) Multiple perforations seen in the small bowel. (D) The resected pathological specimen contained a large synthetic bezoar composed of an aggregate of coiled cylindrical material consistent with wires. Wrapped with the wires are paper, cloth, rubber-like material, and foam.

Figure 2. (A, B, C) Multiple perforations seen in the small bowel. (D) The resected pathological specimen contained a large synthetic bezoar composed of an aggregate of coiled cylindrical material consistent with wires. Wrapped with the wires are paper, cloth, rubber-like material, and foam.

Following the procedure, he was started on total parenteral nutrition. At the time of discharge, he was tolerating a regular diet. He returned to his usual healthy state over the next 3 months.

Diagnosis

Bezoar

Bezoars are classified according to their composition, which may include vegetable matter (phytobezoar); hair (trichobezoar); milk (lactobezoar); or medications (pharmacobezoar). A bezoar can occur anywhere in the gastrointestinal tract, although gastric bezoars are most common. Primary small bowel bezoars without an associated gastric bezoar, as seen in this case, are uncommon. Primary small bowel bezoars can occur within small bowel diverticula, along with strictures and adhesions, and in cases of decreased intestinal motility.1

Pica refers to a perverted appetite for substances not fit as food. It is seen predominantly in children with mental retardation, psychiatric disorders, and autism spectrum disorders. The patient described had a history of swallowing inorganic objects. Eliciting a history of pica is vital in the evaluation of these patients.

Common presenting complaints in a child with bezoar include abdominal pain, nausea, vomiting, halitosis, anorexia, weight loss, and early satiety. Communication difficulties can pose an impediment to localizing pain and identifying if gastrointestinal symptoms are the basis for behavioral changes. Caregivers and health care professionals should be aware of atypical signs of gastrointestinal disorders in patients with developmental delay and autism spectrum disorders.

Physical examination is unremarkable in most patients, but occasionally clinical signs of intestinal obstruction or a palpable mass may be present on examination.

Bezoars are often discovered as an incidental finding in a patient with nonspecific symptoms. Plain abdominal radiographs may not reveal the bezoar. Therefore, symptoms suggesting obstruction warrant more thorough investigation. An upper gastrointestinal tract barium study or computed tomography can be used to outline the mass collected in the stomach and/or the small bowel.

Complications of bezoars include nutritional deficiencies, gastritis, gastric outlet obstruction, gastrointestinal bleeding, constipation, perforation, and intestinal obstruction. The overall incidence of bezoar-induced intestinal obstruction remains relatively low. Epidemiologic data show that 2% to 4% of intestinal obstructions are caused by bezoars.2 When a child has a small bowel obstruction caused by a bezoar, the stomach needs to be evaluated thoroughly because the incidence of concurrent gastric bezoars is approximately 20%.3 Small bowel perforation is a rare complication, induced mostly by sharp foreign bodies and less frequently by pressure necrosis of blunt bezoars.1

Therapy for the bezoars depends on the composition. Available treatment methods include chemical dissolution, endoscopy, and surgery. Emergency laparotomy is required for large obstructing bezoars or bizarre bezoars in the stomach or the small bowel.

Conclusion

Bezoars and foreign bodies are more commonly encountered in children with developmental and psychiatric disorders, particularly associated with pica. Although a bezoar can form anywhere in the gastrointestinal tract, the formation of a primary small intestinal bezoar is rare. When an intestinal bezoar is diagnosed, the possible presence of coexisting gastric bezoar should be investigated. Surgical treatment must be considered in cases of multiple, large, sharp objects or complications.

References

  1. Burstein I, Steinberg R, Zer M. Small bowel obstruction and covered perforation in childhood caused by bizaare bezoars and foreign bodies. Isr Med Assoc J. 2000;2(2):129–131.
  2. 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(6–7):596–600. doi:10.1016/j.gcb.2008.01.045 [CrossRef]
  3. Escamilla C, Robles-Campos R, Parilla-Paricio P, et al. Intestinal obstruction and bezoars. J Am Coll Surg. 1994;179(3):285–288.

Authors

Prita H. Mohanty, MD is a Fellow, Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, University of Rochester Medical Center, Rochester, NY. Megan Gabel, MD, is Assistant Professor, Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, University of Rochester Medical Center, Rochester, NY.

Disclosure: Drs. Mohanty and Gabel have disclosed no relevant financial relationships.

Address correspondence to: Prita H. Mohanty, MD; 601 Elmwood Avenue, Box 667, Rochester, NY 14642; fax: 585-275-0707; email: Prita_Mohanty@urmc.rochester.edu

10.3928/00904481-20120525-07

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