Vegetable Fiber Mass Blocked a 9-Month-Old’s Bowel While Imaging Suggested Intussusception

A nine-month-old boy arrived at a tertiary pediatric surgical center with four days of progressive abdominal distension and vomiting that had turned bilious on the day of transfer. He had never had abdominal surgery, and his feeding history pointed only to recently introduced, home-prepared vegetable foods during weaning; his parents could not identify any single whole food item with certainty. Surgeons exploring his abdomen found a firm, mobile mass lodged in the ileum about 15 centimeters above the ileocecal valve. It proved to be a phytobezoar, a concretion of matted, undigested vegetable fibers, and its removal by enterotomy resolved the obstruction completely. The case, reported in Discover Pediatrics, is paired with a focused review of the published pediatric literature and illustrates how easily this rare condition masquerades as a far more common surgical emergency.

The diagnostic path in this infant was anything but straightforward. An initial supine abdominal radiograph showed multiple dilated small bowel loops with a paucity of distal colonic gas, findings consistent with mechanical obstruction, although a dedicated erect film was not obtained. Targeted ultrasonography then revealed a distinct transition point with a target-like lesion measuring 2.2 centimeters in the right lower quadrant, resembling an intussusception but displaying only an incomplete pseudokidney appearance. With high-grade obstruction persisting and the imaging inconclusive about the underlying cause, the team proceeded to exploratory laparotomy rather than attempting non-operative reduction.

What the surgeons found contradicted the leading imaging impression. There was a marked transition from dilated proximal bowel to collapsed distal bowel, a single large intraluminal concretion within the ileum, and no external bands, volvulus, or Meckel’s diverticulum. The colon and remaining large bowel were collapsed and normal, with no second obstructing lesion. The mass fragmented during delivery through the enterotomy, and gross examination by the operating team confirmed a friable aggregate of undigested vegetable fibers; the specimen was not sent for formal histopathological analysis because the diagnosis was evident macroscopically. The bowel was viable, the enterotomy was closed transversely, and the postoperative course was uneventful. The infant tolerated oral intake by day four, was discharged on postoperative day six, and at outpatient follow-up was thriving and asymptomatic with no recurrence, after his caregivers received dietary counseling on introducing high-fiber foods.

To place the case in context, the authors conducted a narrative review, explicitly not a systematic review and without a registered PRISMA protocol, searching MEDLINE via PubMed, Embase, and Google Scholar from inception to January 2025. They included reports of confirmed phytobezoar-induced mechanical intestinal obstruction in patients aged 0 to 18 years with sufficient clinical detail, and excluded gastric bezoars not causing distal obstruction, trichobezoars, lactobezoars, pharmacobezoars, and non-English reports without accessible translation. Together with the present case, reported per the CARE guidelines, the review identified ten previously published reports, eleven sources in total, summarizing 46 pediatric patients.

The aggregated data revealed a striking bimodal age distribution. The largest published series, by Choi and Kang with 33 patients, reported a mean age of 7 to 9 years, range 3 to 15 years, and was dominated by persimmon ingestion, accounting for roughly two-thirds of that cohort. The remaining reports, including the present case, predominantly involved infants and neonates. Restricting attention to the neonatal and infant subgroup of children aged two years or younger, eight patients were identified across six sources. In this young group the dietary triggers differed markedly from the persimmon-related bezoars of older children: identifiable triggers were reported in a subset, comprising grapes in two cases, mashed potato in three, and parsnip in one, while in the remaining infant and neonatal reports, including the present case, the specific inciting food could not be determined and the bezoar was described simply as impacted vegetable or fibrous matter.

Anatomy favored one location above all others. The terminal ileum was the most frequently affected site across the reviewed literature, consistent with its role as the narrowest and most distal segment of the small bowel, where concretions formed higher in the digestive tract come to lodge. Unusual sites reported in the wider literature include the colon and a bezoar impacted within a Meckel diverticulum. Clinically, vomiting, often bilious, and abdominal pain or irritability were the most consistent presenting features, while abdominal distension and a palpable mass were reported less consistently, particularly in infants in whom these signs are harder to elicit. Plain radiographs generally showed features of small bowel obstruction, ultrasonography sometimes demonstrated a target or arc-like echo with acoustic shadowing mimicking intussusception, and computed tomography, where used, characteristically showed a mottled gas sign.

The sonographic mimicry observed in this infant has been described before in the infant subgroup, and the authors dissect why it occurs. The hyperechoic arc of the bezoar surface produces an acoustic shadow surrounded by edematous bowel wall, generating an appearance that can be mistaken for an intussusceptum. Features that favor phytobezoar over true intussusception include an intraluminal mass with a mottled, gas-containing internal echo pattern, an incomplete rather than a well-formed pseudokidney sign, absence of the multi-layered target with a central mesenteric core and vessels on Doppler imaging, and a mobile mass with a clear proximal-to-distal caliber transition. In adults, twinkling artifacts on color Doppler help differentiate bezoars from feces, but these are difficult to elicit in a crying infant, and CT, despite its characteristic mottled gas pattern, carries radiation risk that limits routine use in infants. The authors also note that the classic currant-jelly stool of intussusception is neither sensitive nor specific, reported in at most about half of cases and in practice considerably fewer, on the order of 20 percent, so its absence neither excludes intussusception nor lowered clinical suspicion in this patient.

The imaging ambiguity raised a natural question: should non-operative enema reduction, the standard first-line treatment for confirmed intussusception, have been attempted before surgery? Several features argued against it. The ultrasound showed only an incomplete pseudokidney sign with a mottled, gas-containing internal echo pattern rather than the classic multilayered target with a discrete mesenteric core, favoring an intraluminal mass over a true intussusceptum. The obstruction was high-grade and progressive, with bilious vomiting at presentation. Moreover, even had the lesion represented a true intussusception, an underlying pathological lead point, which a phytobezoar itself constitutes, is a recognized relative contraindication to enema reduction because of increased risks of reduction failure, bowel wall injury, or perforation. The team therefore went directly to surgical exploration.

Management across the reviewed cohort was overwhelmingly surgical, most often laparotomy with enterotomy and extraction. Manual reduction, or milking of the bezoar into the cecum without opening the bowel, and segmental resection, typically when an underlying anomaly such as a Meckel diverticulum was present, were reported less frequently, and endoscopic retrieval succeeded only for proximally located, endoscopically accessible bezoars. For gastric phytobezoars, chemical dissolution with agents such as Coca-Cola or cellulase has high success, over 90 percent when combined with endoscopy, and pineapple juice has also been suggested, but these measures are contraindicated in acute small bowel obstruction owing to perforation risk. Laparoscopic management of a grape obstruction in a seven-month-old has recently been described, and selected conservatively managed intestinal phytobezoars have been reported, although surgical exploration remains standard whenever high-grade or progressive obstruction is present. Mortality in the review was rare, three of 46 patients, confined to two historical reports marked by delayed presentation and septic complications.

The prognosis for pediatric phytobezoar obstruction is excellent following timely intervention, with negligible mortality in modern series, a marked improvement over historical reports in which delayed diagnosis led to sepsis and death. Recurrence is rare provided dietary habits are modified, and the authors emphasize counseling caregivers on the appropriate introduction of high-fiber foods and avoidance of whole grapes, unpeeled fruits, or large vegetable chunks until adequate masticatory function is achieved. Because this was a single case paired with a small narrative review rather than a systematic analysis, the evidence base remains limited to isolated experiences, and management guidance is drawn from case reports rather than large-scale studies. Even so, the central message is concrete: in an infant with bilious vomiting, distension, and imaging that resembles intussusception but lacks its classic features, a phytobezoar in a structurally normal abdomen deserves a place on the differential diagnosis, and early surgical exploration is both diagnostic and curative.

Subject of Research: Phytobezoar-induced small bowel obstruction in infants mimicking intussusception

Article Title: Phytobezoar induced small bowel obstruction mimicking intussusception in early infancy a case report and literature review

Article References: Al Blooshi, M., Ahmad, M., Gupta, V., & Jaber, G. (2026). Phytobezoar induced small bowel obstruction mimicking intussusception in early infancy a case report and literature review. Discover Pediatrics, 1(1), Article 13. https://doi.org/10.1007/s44571-026-00013-5

Image Credits: AI Generated

DOI: 10.1007/s44571-026-00013-5

Keywords: phytobezoar, small bowel obstruction, intussusception mimic, infant, terminal ileum, enterotomy, pediatric surgery, ultrasonography, dietary fiber, case report, literature review, weaning