Clinical History
8-year-old girl with no past medical or surgical history presented with a 3-month history of abdominal pain and distension with weight loss.
Imaging Findings
CT abdomen and pelvis revealed an intraluminal mass with some soft tissue densities in the stomach, duodenum and proximal jejunal loops. The mass showing air lucencies in the interstices was partially adherent to the stomach and bowel wall. Obstruction was evident in stomach, duodenum and proximal jejunal loops.
Discussion
Background:
Bezoars are agglomerations of food or indigestible material in the gastro-intestinal (GI) tract. [1] Bezoars are classified according to their primary constituent, the most common types being trichobezoars (hair) or phytobezoars (plant material). [2] Trichobezoars occur primarily in girls who ingest their own hair, and are usually confined within the stomach. [2] The earliest reference on the bezoar was made by Sushruta in India and dates back to the 12th century BC. The first reference to a bezoar in Western countries was reported in 1779 during an autopsy of a patient who died from gastric perforation and peritonitis. [3, 4] It is also called Rapunzel syndrome, mainly reported in women (>95% of cases), however, 2 men have also been reported, which may be attributed to the traditionally long hair in women [5].
Clinical features:
Symptoms of this disease are very vague and varied. Most common presenting symptoms are abdominal pain (46.66%), nausea and vomiting (44.44%), obstruction (20%), abdominal distension (8.88%), weight loss (8.88%), peritonitis (6.66%), abdominal mass (6.66%), sepsis (2.2%), cardiac arrest (2.2%) and unusual pallor (2.2%). [5]
Diagnostic workup:
After detailed clinical history and examination, various radiological investigations can help in reaching the diagnosis.
Abdominal radiograph: trichobezoar cannot be diagnosed alone on plain radiograph, however, it can show distended stomach shadow with an intragastric mottled gas pattern [5]
Fluoroscopy: barium studies: may show filling defect in the stomach or small bowel loops with mottled air lucencies without attachment to the bowel wall. After some time the interstices of trichobezoar become filled with barium. The exit of barium is very slow if there is underlying obstruction and the contrast will be seen in the lumen for a longer time than normal.
Ultrasound: can show echogenic mass with acoustic shadow within stomach, pylorus or small bowel loops.
CT: is the imaging modality of choice for showing the size, location, associated obstruction and complications. In our case CT revealed an intraluminal mass with some soft tissue densities in the stomach, duodenum and proximal jejunal loops. The mass showing air lucencies in the interstices was partially adherent to the stomach and bowel wall.
Conclusion:
Surgeons, physicians, and radiologists should consider trichobezoar in the differential diagnosis of gastrointestinal obstruction in young women, especially in the presence of an upper abdominal mass. In the past, bezoars were rarely diagnosed prior to surgery, but advances in imaging suggest that CT can help radiologists to diagnose bezoars prior to surgery, which improves clinical management. [3]
Differential Diagnosis List
Trichobezoar in stomach, duodenum and proximal jejunal loops
Gastrointestinal tumour
such as a GIST extending into the stomach lumen
Small bowel faeces sign (SBFS)
Final Diagnosis
Trichobezoar in stomach, duodenum and proximal jejunal loops