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Mountain Papaya Seeds Causing Fecal Impaction in Children

Julie Ituku, Mathenge Nduhiu

Nyeri County Referral Hospital, Nyeri, Kenya

Correspondence to: Dr. Julie Ituku. P.O Box 64964-00620 Nairobi, Kenya. Email: juliegituku@gmail.com

Summary

Stool retention more commonly affects children. It is a clinical finding in which a child resists bowel movements resulting in infrequent defecation, which then becomes larger and more painful. If left unaddressed, it may result in fecal loading or fecal impaction. Fecal impaction is a common gastrointestinal problem and a potential source of morbidity. Prompt identification and treatment therefore minimize the risks of complications. Treatment options include manual disimpaction and proximal or distal washout in the absence of complications. We report 3 cases of children who presented in the past 2 years, with stool retention due to undigested mountain papaya seeds.

 

Key words: Prickly mountain papaya seeds, Stool retention, Fecal impaction, Manual evacuation.

Ann Afr Surg. 2017; 14(2):113-116 DOI:http://dx.doi.org/10.4314/aas.v14i2.13

© 2017 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Fecal impaction is a common gastrointestinal disorder and a source of significant patient discomfort with potential for major morbidity especially in the pediatric and elderly population (1). Commonly found in the rectum, it is defined as the inability to evacuate large hard inspissated concreted stool or bezoar lodged in the lower gastrointestinal tract. It is also known as coprostasis or inspissated stool syndrome (1). Stool retention in children is a known precipitating factor. Literature has reported cases due to seeds such as pumpkin, watermelon, pomegranate, sunflower and prickly pear (2). We are however unaware of cases reported due to mountain papaya seeds, particularly in Kenya. We report 3 cases of children who presented to Nyeri County Referral Hospital during the past 2 years, with fecal retention due to undigested mountain papaya seeds with complications necessitating extensive treatment, including manual disimpaction and in one case colostomy. Nyeri County Referral Hospital is the largest of the 7 public hospitals in Nyeri County, which covers an area of 3,337.2 km2, with a population of approximately 720,708 people (3). On average, 204,000 people are seen at the hospital annually, 5% of who are below the age of 18 years.

Case 1

In September 2014, a 9-year-old girl presented with a 3-day history of failure to pass stool, which was gradual in onset with normal bowel movements prior. Since then, she reported worsening abdominal discomfort with inability to pass stool even when the urge arose. She was noted to have eaten a mountain papaya (pulp and seeds included) 1 week prior to admission after which she had eaten her usual diet. She reported no history of abdominal distension, abdominal pain, vomiting, anal pain, obstipation or hematochezia. No significant past medical history was reported. At a peripheral facility, several attempts at manual evacuation and enemas were unsuccessful.

Physical examination revealed a sick-looking child who was restless and in obvious pain but had normal vital signs. The abdomen was not distended, moved with respiration, was soft, non-tender and, with normal bowels sounds. There was tenderness on digital rectal examination with hard stool and prickly seeds noted on the blood stained examining finger. The patient was put on a laxative and enema.Two days later, she passed minimal hard stool with pain noted on defecation.No obstructive symptoms had been reported.

 

​On physical examination, she was still sick looking with normal vital signs. The abdomen was slightly distended, moving with respiration, tense and tender on palpation with normal bowel sounds. Inspection of the anal region revealed an edematous and inflamed anal orifice with visible impacted stool. A decision was made to take the child to theatre for examination under anesthesia (EUA) and manual evacuation. Informed consent was obtained from her guardian.In theatre, the patient was sedated and positioned in lithotomy position. On examination, the anal opening was patulous with surrounding excoriation. There were infected deep anterior and posterior anal tears exposing the internal anal sphincter fibers. The feces were then evacuated digitally and the rectal wall examined and found to be edematous with adherent fibrinous exudate. Intraoperatively, the decision was made to divert stool post evacuation to allow healing. A divided sigmoid colostomy was fashioned and reversed 5 months later. There was a delay in reversal of the stoma due to difficulty finding theatre space for elective procedures in our hospital.

 

Case 2

In May 2015, an 8-year-old boy presented with a history of abdominal pain, abdominal distension, vomiting and failure to pass stool for 5 days. He had no significant past medical history. He reported eating mountain papaya with the seeds prior to the onset of symptoms. A soapy enema had been attempted