Swallowed "Santol" Seeds Causing Surgical Abdomen
Oliver S. Leyson, MD
Edgardo P. Penserga, MD,
FPCS
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Department of Surgery
Ospital ng Maynila Medical
Center
Swallowed santol seeds
Reprint Request: Oliver S. Leyson, M.D.
Department of Surgery, Ospital ng
Maynila Medical Center
Swallowed "Santol" Seeds Causing Surgical Abdomen
Abstract
A Filipino patient who swallowed santol seeds, then developed surgical abdomen secondarily to perforated large intestine, and who eventually died is being reported to create awareness among health professionals and the public of the potential of swallowed santol seeds causing surgical abdomen and it posing as a public health problem. Discussion focused on the approximate magnitude of the health problem in the Philippines (about 200 cases annually) and strategies for primary (not to swallow santol seeds at all cost) and secondary prevention (close monitoring for adverse events after accidental swallowing of santol seeds and early medical consult).
Key words: santol seeds, foreign bodies in the gastrointestinal tract
Swallowed "Santol" Seeds Causing Surgical Abdomen
Oliver S. Leyson, MD
Edgardo P. Penserga, MD,
FPCS
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Introduction
"Santol" are tropical fruits which are abundant in Southeast Asia. Its scientific name is Sandoricum koetjape. The fruit is usually yellow-brown in color and has a thick fleshy skin and several seed-containing segments inside. There are about 3-4 seeds per santol fruit. The peeled skin of the santol fruit is usually eaten and the juicy pulp attached to the seeds sucked. Some people swallow the seeds but most do not. Swallowing the santol seeds may be inconsequential as these are often passed out through the anus without causing any health problem. However, in some instances, swallowing the seeds may have adverse effects in the form of obstruction and perforation of the intestine.
This is a case report of a Filipino patient who developed a surgical abdomen after swallowing santol seeds.
There are two reasons why this case report is being made. One is for the benefit of the health professionals - to make them aware that swallowing santol seeds is a potential cause for surgical abdomen. Awareness will facilitate early and correct diagnosis and early treatment thereby promoting successful patient management. Two is for the benefit of the public - to make them aware that swallowing santol seeds is a potential cause for surgical abdomen. Awareness will promote avoidance of swallowing of santol seeds thereby reducing the incidence of surgical abdomen related to such act and its attendant mortality and morbidity consequences.
Case Report
M.J., 47-year-old Filipino female vendor consulted Ospital ng Maynila Medical Center (OMMC) with a chief complaint of abdominal pain most severe at the left lower quadrant.
The patient claimed she swallowed 10 Bangkok santol fruits 7 days prior to consult. Three days prior to consult, she experienced abdominal pain at the left lower quadrant with loose bowel movement. One day prior to consult, abdominal pain increased in severity accompanied by high grade fever.
Physical examination showed a conscious, coherent, oriented female with the following vital signs:BP=160/100; CR=106/min; RR=22/min; T=39.5 C. The pertinent findings were focused on the abdomen which was globular, with hypoactive bowel sounds and direct and rebound tenderness on all quadrants.
The admitting diagnosis was an acute surgical abdomen secondarily to perforated viscus most likely secondarily to swallowed santol seeds. The bases consisted of signs of peritoneal irritations, pneumoperitoneum on chest upright film and history of swallowing santol seeds. The attending surgeons had high index of suspicion that the cause of the surgical abdomen was due to swallowed santol seeds because of the occurrence of such cases in the department in the past.
Patient was operated with findings of 3 points of perforation in the descending and sigmoid colon secondarily to the swallowed seeds. There was generalized fecal peritonitis. About 16 santol seeds were seen on the resected colon. There was no abnormality on the colon aside from the perforations.
A segmental colonic resection was done with the proximal end (left transverse colon) brought out as an end-colostomy and the distal end (rectosigmoid colon) closed. Peritoneal lavage was done.
Despite all measures to control the infection initiated by the fecal peritonitis, the patient died on the 4th hospital day of multiple organ failure (lungs and kidney) secondary to sepsis.
Discussion
Search of literature showed only four articles on the adverse effects of swallowed santol seeds. One is a report from Thailand (1) on sigmoid colon perforations secondary to swallowed santol seeds. The other three are reports from the Philippines (2-4). One of these Philippine reports is a case series from a tertiary government hospital consisting of 10 cases operated on for intestinal obstruction and perforation from 1986 to 1996 (2). The second paper is a case report intended for a health advisory published in a national daily (3). The third paper is also a case series on colonic perforation caused by santol seeds (4).
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 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. 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 July to October 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 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.
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 (2). 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. Ramirez et al (4) cited a 50% morbidity and a 30% mortality rate.
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.
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 July to October 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.
Summary
A Filipino patient who swallowed santol seeds, then developed surgical abdomen secondarily to perforated large intestine, and who eventually died is being reported to create awareness among health professionals and the public of the potential of swallowed santol seeds causing surgical abdomen and it posing as a public health problem. Discussion focused on the approximate magnitude of the health problem in the Philippines and strategies for primary and secondary prevention.
References
1. Somboonpamya P. Sigmoid colon perforation by ingested Sandorica seeds. J Med Assoc Thai 2001; 84(12):1751-3.
2. Velayo BM, Doble FC, de los Santos N, Talens, ESM. Ten cases of intestinal obstruction and/or perforation associated with ingestion of fruit seeds. Philip J Surg Spec 1998; 53(2):61-63.
3. Castillo RR. The case of the deadly santol seeds. Phil Daily Inquirer 2001; Sept 7.
4. Ramirez JG, Crisostomo A, Gutierrez R, Roxas A. Colonic perforation associated with "santol" seeds. Asia J Surg 1993; 16(3):232-5.
Pictures of "Santol"