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Swallowed santol seeds causing surgical abdomen as a public health problem

Reynaldo O. Joson, MD

Chair, Department of Surgery

Ospital ng Maynila Medical Center



How common is “swallowed santol seeds causing surgical abdomen” in the Philippines?

In the Philippines, there is no registry that keeps track of the incidence of swallowed santol seeds causing surgical abdomen. From informal communications among surgical colleagues, however, the perception is that there are actually a lot of cases of swallowed santol seeds causing surgical abdomen, especially in government hospitals. Ospital ng Maynila Medical Center (OMMC) had 2 cases in 2001. Likewise, Philippine General Hospital had 2 cases in 2001. Davao Regional Hospital had 2 cases in 1999, 1 case in 2001, and as of July, 2002, 2 cases. In 2002, OMMC had 3 cases. The estimate is that there are about 2 cases per year in each tertiary government hospital in the country. With about 100 tertiary government hospitals in the Philippines, the caseload per year usually occurring during the May to August season month of santol would roughly be about 200. Such a caseload is considered a public health magnitude considering the preventable nature of the condition. This should call for concerns and action from the local health authorities.

Why do Filipinos swallow santol seeds?

Why santol seeds are being swallowed by Filipinos? It could be unintentional. If it is intentional, it is most likely eating enjoyment together with the perception that the seeds can be swallowed without any adverse effect.

What are the dangers of swallowing santol seeds?

In the Philippines, the variety presently abounding in the market during the season of santol is the Bangkok santol which is one and a half times bigger than the previous variety. The Bangkok santol seeds are also bigger, about 3 cm in length, and have sharper edges. Before the advent of Bangkok santol in the Philippines, there were already reported adverse events associated with swallowing of the seeds of the previous variety. The adverse events were usually obstruction of the intestine and rarely perforation. The usual scenario was the presence of prior structural narrowing of the intestine, usually caused by tuberculosis or malignancy, with the obstruction being completed by the swallowed santol seeds. In patients with perforation, the adverse event was usually an aftermath of an obstruction or because of the presence of existing structural defect in the form of thinning out of the intestinal wall such as in diverticulum. With the advent of swallowing Bangkok santol seeds, which are bigger and have sharper ends, the most common adverse event seems to be primary perforation even in the absence of structural defect in the colon. As seen from the Thailand and Philippine case series, most of the perforations occurred at the sigmoid colon, which is the distal part of the large intestine, near the rectum. A possible explanation for predilection in this segment of the large intestine is that by the time the seeds reach the sigmoid colon, the fibers attached to the seeds have already been digested leaving the sharp ends of the seeds exposed to cause direct damage to the intestinal wall.

The mortality and morbidity rates of the surgical abdomen resulting from swallowed "santol" seeds are usually dependent on the time of consult and treatment. Late consult and treatment are usually associated with a high mortality and morbidity rate as high as 30% and 50% respectively.

Why is it considered a public health problem?

Death from swallowed santol seeds and operations done in these patients should be considered unnecessary because the etiology is totally preventable and the death is considered premature. With the death being unnecessary and preventable and with the incidence of about 200 cases per year in the Philippines, swallowing santol seeds should be considered a public health problem.

What are strategies to reduce the public health problem of swallowed santol seeds?

The best strategy to solve the public health problem of swallowed santol seeds is primary prevention. This consists of, first, creation of awareness of the danger of swallowing the seeds and second, education to promote a habit not to swallow the seeds (anymore for those who have acquired a habit of swallowing) at all cost.

A secondary prevention is to prevent the morbidity and mortality associated with swallowed santol seeds. Public health education is the best tool for this. The public should be told what to do when santol seeds are unintentionally swallowed. They have to watch out for abdominal pain. Once there is abdominal pain, they should consult an abdominal surgeon as soon as possible to avoid late diagnosis of an abdomen that may need an operation because of intestinal perforation.

On the part of the physicians and surgeons when they are consulted, they can help reduce the mortality and morbidity rates associated with management of patients with surgical abdomen secondary to swallowed "santol" seeds by early diagnosis. Early diagnosis can be promoted by a knowledge that surgical abdomen can be caused by swallowed santol seeds as well as by a high index of suspicion in patients who have swallowed santol seeds and a surgical abdomen occurring during the season months of santol, from May to August in the Philippines.

An additional activity that should be done in solving the public health problem of swallowed santol seeds causing surgical abdomen is to come out with a registry to measure the incidence and monitor the magnitude of the problem. A registry can be established by any concerned health institution, such as Department of Health, Philippine College of Surgeons or Philippine Society of General Surgeons.

The Department of Surgery of Ospital ng Maynila Medical Center has taken the initiative to establish the registry in 2002 and issue out health advisory as early as 2001.