Swallowed “ Santol” Seeds As Cause of Surgical Abdomen
Oliver S. Leyson M.D.
Department Of Surgery
Ospital ng Maynila Medical Center
INTRODUCTION
Santol like other tempting fruits is so sweet and tasty that somebody who enjoys eating one might lead to swallowing the so called “Lolly Fruit” after extracting the juicy pulp through sucking it and enjoy its rich flavor as the flesh sticks to the seed. This seed came from our very famous Santol fruit, was characterized as hard oval in shape with sharp pointed in one end. It measures up to ¾ in (2cm) long, intimately attached to the seed is a slippery pale white to translucent succulent pulp1.
Many Filipinos enjoy the habit of swallowing the seeds after they felt the tingling sensation they get from the soft pulp without knowing that they are exposing themselves in a potential life threatening condition.
In the case of a 55-year-old female, who enjoyed swallowing santol seeds.She developed severe abdominal pain and distension. Sought consult to Ospital ng Maynila Medical Center and was found to have an acute abdomen secondary to a ruptured viscus. On explor laparotomy several santol seeds were noted with the pointed tip of the seed protruding out of the wall of the intestines2.
Cases of intestinal obstruction or perforation secondary to santol seed ingestion are not commonly seen in the western part of the world because of the origin and distribution of the fruit. It is commonly cultivated and believed to be a native from Indochina, especially Cambodia and Southern Laos3.
This similar case. although rare can cause a serious health danger to anyone and not all health professionals are aware of the high risks it may brought to human lives. Since every year, Santol season in the Philippines were projected from the month of July to October1, this would be the best time to facilitate a seminar and educate them on the danger of swallowing santol seeds.
CASE REPORT
A 47 year old female from Bacoor, Cavite was seen in the emergency room of Ospital ng Maynila Medical Center presenting with a progressive abdominal pain localized on the left lower quadrant and becoming generalized associated, with distention of five days duration. The patient claimed she swallowed 10 santol seeds one week prior to consult.
On physical examination patient had a BP of 160/100, CR=106/min RR=22/min T=39.5. Abdominal findings revealed a globular, distended abdomen with hypoactive bowel sounds, with direct tenderness and involuntary muscle guarding on all quadrants. Digital rectal examination revealed a collapsed and empty rectal vault with good sphincter tone. Chest x-ray and plain abdominal roentgenogram was done which showed pneumoperitoneum and distended bowels respectively ( figures 2 & 3). The initial assessment was a generalized peritonitis secondary to a ruptured viscus.
An exploratory laparotmy was done. Upon opening up, 350 cc of yellowish purulent foul smelling peritoneal fluid was noted. Gross fecal contamination with interloop abscess were seen in all quadrants. Multiple descending colon perforations were noted . A single perforation was noted in the sigmoid colon. A santol seed was protruding through the perforation. Total number of santol seeds recovered was 16. A Hartmann’s procedure was done.. However, on the second hospital day the patient developed septic shock that lead to her demise.
DISCUSSION
Ingestion of Sandorica, more commonly known as santol seeds causing descending or sigmoid perforation is a rarely reported case worldwide. Literature search showed only 3 related studies, one in Thailand and the other two were in the Philippines. Hence the actual incidence of this case is not yet established.
As reported by Somboonpanya P. 1 in his study, 9 patients were seen in Prachowklao Hospital in Thailand, from 1996 to 2002. Most of the cases were elderly with mean age of 65 years ( range 57-58). The main symptoms were abdominal pain with generalized peritonitis, and severe tenderness at the suprapubic area, ileus and persistent vomiting. In all cases, the diagnosis was made at operation, with removal of the seed, closure of the perforation at the rectosigmoid colon with simple suture and proximal transverse loop colostomy.
In the Philippines, a study was found published in PJSS last 1998 entitled, “Ten Cases of Intestinal Obstruction and Perforation Associated with Ingestion of fruit seeds”2. Ten patients presented with intestinal obstruction and/or perforation secondary to fruit seed, admitted at East Avenue Medical Center from 1986-1996. The presenting signs and symptoms were right lower quadrant pain and tenderness, intestinal obstruction , right lower quadrant mass and peritonitis. Eight cases were associated with ingestion of santol seeds. Three cases were found to have ileo-cecal tuberculosis and the other two have diverticulitis. All patients were managed surgically.
Most Filipinos are known to have the habit of swallowing fruit seeds. Santol seed is the most common fruit seed swallowed which can cause intestinal obstruction perforation (7), followed by star apple or Kaimito (1), mixed Santol and Kaimito (1) and one unknown seed (1)3 . The seed which is indigestible, which when taken in significant number, forms a bulk in the stool, which can eventually cause obstruction of the large intestines. The sharp pointed end of the seed may cause perforation of the lumen during the powerful peristaltic movement of the colon.
In a related review, a study done by Henderson et al 8 states that most of the ingested objects entering the gastrointestinal tract will uneventfully be passed out . A large number of reports support the belief that perforation is more common with sharp or pointed objects .
The pathophysiology of swallowed seeds causing intestinal perforation is not clear. However it is a common belief that pressure necrosis exerted by the hard object such as santol seeds may consequently perforate a bowel1. Several mechanism was proposed by some authors to explain the higher predilectation of the sigmoid perforation. First, distal colon have relatively poor blood supply. Secondly fecal content become dehydrated as it reaches the distal colon hence, scybalous are likely to form here. Thirdly, the sigmoid and the rectosigmoid being the distal part of the colon can generate high intraluminal pressure. The presence of hard stool or a foreign body like santol seeds can cause pressure necrosis ulceration and perforation of the bowels.1
Mortality and morbidity rates of ill consequences of swallowed santol seeds were still very high as reported by Ramirez et al with a 50% morbidity and a 30% mortality.1
The aim of this case report is for everyone to know and be aware especially the people concerned that there is such a condition brought about by the swallowing of the deadly santol seeds. People who already swallowed the seed should be on guard for the abdominal signs and symptoms, such as severe abdominal pain and distention. Fortunately, when the patient is asymptomatic, the seeds may have just passed out the anus without causing any complication.
SUMMARY
This is a case of a 47 year old female with a history of generalized abdominal pain that started on the left lower quadrant and on physical examination diagnosed to have an acute surgical abdomen secondary to a ruptured viscus. On explor laparotomy showed a multiple descending and sigmoid perforation secondary to Santol seeds. Very few cases were reported and available on literature search. The aim of this report is to inform the health professionals and the public of the potential danger it poses on the lives of people who are fond of swallowing santol seeds.
Key words: Santol seeds, ingestion, perforation, surgical abdomen
References:
1) Ramirez, Carlo G, Crisostomo Armando, Gutierrez, Romeo, Roxas Alberto. Colonic Perforation Associated with “Santol” Seeds. Asian Journal of Surgery;Colorectal Surgery 1993;16 (3):232-5.2
2) Morton, Julia F.: Santol. In : Fruits of Warm Climates; Miami Florida p.199-201.
3) Velayo B. M. MD; Doble, F.C. MD, FPCS; Delos Santos, N. MD FPCS; Talens E MD FPCS. Ten Cases of Intestinal Obstruction and/or Perforation Associated with Ingestion of Fruit Seeds
4) Anonymous: Santol-Tropical Fruits We Grow:Cape Trib Exotic Fruit Farm; Lot 5 Nicole DriveCape Tribulation Queensland 4073 Australia 2002.
5) Samboonpamya P.Sigmoid colon perforation by ingested Sandorica Seeds; J Med Assoc, Thai, 2001 Dec; 84(12):1751-3.
6) Anonymous: Case of Deadly Santol Seed Inquirer New Service Sept 2001
7) Anderson CT, Engel J, Schlesinger. Foreign body ingestion: review and suggested guidelines for management. Endoscopy 1987;19: 68-721.
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