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Giant gastric trichobezoar

CASE REPORT

Giant Trichobezoar Induced Intestinal Obstruction in A Child—


A Case Report

Hsien-Pin Sun

Division of General Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan

ABSTRACT
Bezoars are masses of solidified organic or nonbiological material commonly found in the stomach and small bowel. Although
phytobezoars are now the most common type reported and are usually associated with previous gastric surgery and abnormal
emptying, trichobezoars still occur most frequently in younger patients. More than 90% are found in girls, usually in adolescence.
We present a 9-year-old girl with concomitant giant gastric trichobezoar and ileal trichobezoar causing intestinal obstruction. Sur-
gical retrieval of these trichobezoars was done successfully. The girl recovered well and no recurrence was noted. (Tzu Chi Med J
2005; 17:433-436)

Key words: trichobezoar, trichotillomania, trichophagia, intestinal obstruction

INTRODUCTION CASE REPORT

A bezoar is a concretion of material ingested over A 9 year-old, short-haired girl presented in the
time in the lumen of the digestive tract. It is usually emergency department with complaints of abdominal
formed in the stomach. The mass, or part of it, may pass pain and vomiting for several weeks. The girl was rela-
into the small intestine and then become impacted [1]. tively thin. She had recurrent attacks of mild abdominal
Bezoars have been classified into four types based on pain. The abdominal pain was cramping in nature and
their composition: phytobezoar (vegetable), trichobezoar was relieved by vomiting several hours after eating.
(hair), lactobezoar (milk curd), and miscellaneous Physical examination revealed a huge, non-tender,
(medications, tissue paper, shellac, tar, sand, and fungus) mobile, firm protruding mass occupying the epigastric
[2]. Phytobezoars are now the most common type re- and left subcostal regions of the abdomen. Her lower
ported and are usually associated with previous gastric abdomen was distended and bowel sounds were
surgery and abnormal emptying. However, trichobezoars hyperactive. Her vital signs were normal. Laboratory
occur more frequently in children [3]. More than 90% data including complete blood cell count, electrolytes,
present in girls, usually in adolescence. We present a liver function tests, blood urea, serum creatinine, and
case of gastrointestinal trichobezoar- induced intestinal serum amylase were all within the normal range. KUB
obstruction. showed local ileus over the lower abdomen (Fig. 1).
Abdominal computed tomography showed a heteroge-
nous intraluminal mass in the stomach with characteris-
tic minute air bubbles within the mass (Fig. 2). Her

Received: July 26, 2005, Revised: August 16, 2005, Accepted: August 25, 2005
Address reprint requests and correspondence to: Dr. Hsien-Pin Sun, Division of General Surgery, Department of Surgery,
Buddhist Tzu Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan

Tzu Chi Med J 2005  17  No. 6 QPP


H. P. Sun

mother mentioned that this little girl had a history of


trichotillomania with trichophagia starting at about 3
years of age. A psychiatrist had been consulted at that
time but therapy had been discontinued. Her mother tried
to stop this behavior, but family members still noted oc-
casional episodes of trichophagia. Eventually her hair
was cut very short. According to the history and imag-
ing studies, gastrointestinal trichobezoar- induced intes-
tinal obstruction was diagnosed and an exploratory lapa-
rotomy was performed. A 16 × 8 × 8 cm sized gastric
trichobezoar with extension through the pylorus was
noted and removed through a gastrotomy. Another 10 ×
4 × 4 cm sized trichobezoar causing ileal obstruction at
the ileocecal valve was also removed through an
ileotomy (Fig. 3A, 3B). The patient was discharged 6
days after surgery after an uneventful recovery. A psy-
chiatric consultation for trichotillomania was arranged.

Fig. 1. KUB shows local ileus over the lower abdomen


(arrow).

Fig. 2. Abdominal CT shows a large heterogenous intralu-


minal mass occupying almost the entire stomach. It
consists of concentric whirl-shaped rings of different
densities with minute air bubbles (arrow) within the B
mass.
Fig. 3. (A)The large gastric trichobezoar. (B)The trichob-
ezoar impacted at the ileocecal valve.

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Giant gastric trichobezoar

wall. Sonographic examination usually reveals a broad


DISCUSSION
band of high-amplitude echoes superficially with com-
plete shadowing posteriorly [10]. On computed tomog-
Bezoars have been known of since the 12 th cen- raphy, a trichobezoar appears as a large heterogeneous
tury B.C. The term bezoar is derived from the Arabic intraluminal mass occupying almost the entire lumen. It
“Bazehr” or the Persian “Panzehr”, both meaning consists of concentric whirl-shaped rings of different
counterpoison or antidote [4]. More than 90% tricho- densities. Minute air bubbles within the mass are usu-
bezoars are found in girls younger than 20 years and ally present. There is no attachment to the gastric wall.
most are found in children. Entrapped air within the mass is a helpful sign suggest-
Most patients have symptoms that develop insidi- ing the diagnosis [11]. Trichobezoars may produce com-
ously within less than 1 month. When symptoms are plications such as bleeding, hematemesis, gastric
evident and medical attention is sought, the trichobezoars ulceration, intestinal obstruction, perforation, peritonitis,
are usually very large. Common complaints include ab- pancreatitis [12], obstructive jaundice [13], malabsorp-
dominal pain, nausea and vomiting, hematemesis, tion, protein losing enteropathy, superior mesenteric
bloating, early satiety, weight loss, diarrhea, and con- artery syndrome [14], intussusception [15], and appen-
stipation. As obstruction progresses, postprandial vom- dicitis [16]. In mechanical bowel obstruction secondary
iting and colicky abdominal pain may occur. There are to a long, fixed trichobezoar, hyperactive peristalsis
no pathognomonic symptoms or signs frankly related to causes the bowel to be drawn up tightly on the mesen-
bezoars. Uncommonly, patients with trichobezoar may teric side of the intestine. Because of this tethering
vomit or pass hair fragments in the stool [5]. The typical pressure, necrosis may develop along the mesenteric
clinical picture in patients with a trichobezoar is an ado- border of the intestine. This rare condition, called
lescent girl with anorexia, weight loss and abdominal Rapunzel Syndrome, was first described by Vaughan
discomfort with a history of trichophagia. Approximately ED, et al [17]. Rapunzel was the long-haired heroine of
10% of patients show mental retardation or psychiatric a tale told by Jacob and Wilhelm Grimm in 1812. Our
abnormalities termed "trichotillom-ania", and half of patient did not develop a long, fixed trichobezoar, pos-
patients have a history of trichophagia [6]. However, sibly because her hair was cut short.
most individuals with trichophagia do not develop Removal of the trichobezoar is indicated whenever
bezoars. it becomes the leading point of intestinal obstruction.
Trichotillomania is a rare disorder characterized by Most authors treat large trichobezoars surgically [18].
impulses to pull out one's own hair. It is a chronic con- Other treatment modalities including the use of pro-
dition primarily affecting females. The onset is in early teolytic or cellulase enzymes [19], mechanical endo-
childhood or adolescence with a peak between 11-15 scopic disruption of the bezoar by using a pulsating jet
years of age. Trichobezoars have also been reported to of water, suction, lavage, baskets, lithotripsy devices,
include the hair of other humans, dolls, toys, animal lasers [20,21], and extracorporeal shock wave lithotripsy
bristles, raffia, carpet fiber, and wool from clothes or [22]. Successful laparoscopic removal of trichobezoars
blankets. They have also been seen in rabbits and kan- has also been reported [23]. However, traditional lapa-
garoo rats [7]. rotomy is still widely adopted. If feasible, the bezoar is
Trichobezoars develop from hair trapped within the removed through a single enterostomy. However, if there
gastric folds. It is postulated that hair strands, too slip- is evidence of mesenteric necrosis or sealed off
pery to be propulsed, initially become enmeshed. This perforations, it is suggested that multiple enterostomies
creates a mass in the shape of the stomach [8]. be used to reduce tension placed on the mesenteric bor-
Trichobezoars are invariably black (from denaturation der when removing the mass. After removal of the
of protein by acid), glistening (from retained mucous), trichobezoar, the stomach and bowel should be inspected
and foul smelling (due to the decomposition of food resi- carefully for evidence of perforation and palpated for
dues which are interspersed within the hair) [9]. any residual bezoar, as a residual trichobezoar may cause
Physical examination sometimes demonstrates persistent obstruction.
alopecia and usually reveals a moveable mass in the A trichobezoar should always be considered in
upper abdomen. Bezoars have been diagnosed by vari- younger patients presenting with a mobile upper abdomi-
ous imaging modalities. A bezoar in the stomach may nal mass and a history of trichophagia. Diagnosis and
appear on a plain abdominal film as a gastric mass, some- treatment are not difficult with modern modalities. A
times outlined by gas. On a barium study it presents as multidisciplinary approach to these patients should be
an intraluminal filling defect with no attachment to the emphasized and adopted. Psychiatrists and psychothera-

Tzu Chi Med J 2005  17  No. 6 QPR


H. P. Sun

pists should be consulted postoperatively as trichobezoar 11. Gayer G, Jonas T, Apter S, et al : Bezoars in the stom-
may recur if underlying emotional stress factors are not ach and small bowel--CT appearance. Clin Radiol 1999;
resolved [24]. 54:228-232.
12. Shawis RN, Doig CM: Gastric trichobezoar associated
with transient pancreatitis. Arch Dis Child 1984; 59:994-
995.
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