Teaching Case

9 yr old girl with abdominal mass and vomiting. Patient known to have Autism. Parents had noticed her eating her own hair.

9 year old girl referred by GP to out-patient department with 2 month history of feeling unwell and possible splenomegaly on examination. Initially presented to GP with acute abdominal pain and vomiting which settled. Ongoing symptoms of nocturnal emesis and weight loss. Previous diagnosis of Autism with speech delay and learning difficulties. Parents reported a history of the patient eating her own hair and had noted strands of hair present in the vomitus. Clinically the patient was anorexic. Laboratory tests revealed iron deficiency anaemia. On clinical examination a large palpable mass was present over the epigastrium and left hypochondrium. This mass was visible on clinical inspection and non-tender on palpation. Normal bowel sounds. No peritonism. No hepatomegaly. The patient did not have any noticeable hair-loss. Abdominal radiograph was not performed. Ultrasound of Abdomen was carried out which identified a large mass in the midline with hyperechogenicity superficially and acoustic shadowing deeper (Figure 1). Liver, spleen and kidneys were unremarkable. Immediate evaluation of the GI Tract with a Barium meal was arranged. Barium meal revealed a distended stomach containing debris with delayed gastric emptying. The stomach occupied most of the abdominal cavity (Figure 2,3,4). The patient underwent a laparotomy and a large trichobezoar was removed from the stomach (Figure 5).

A bezoar is a mass of ingested substance which remains in the stomach and small bowel. A trichobezoar is the most common type and consists of hair. Phytobezoars are derived from poorly digested vegetable skins and seeds; the most common is persimmon. Lactobezoars, which are associated with high-strength milk feeds or undiluted milk, are now extremely rare. As the trichobezoar grows larger recurrent bouts of nausea, vomiting, epigastric pain and occasionally haematemesis can occur because of intermittent gastric outlet obstruction. The growing bezoar can cause compression and repeated mechanical irritation, leading to chronic inflammation of the gastric mucosa; Menetrier disease, gastric polyposis and protein-liosing enteropathy with steatorrhea have been described. Iron deficiency anaemia is a common laboratory finding and may be a result of impaired gastrointestinal obstruction, but was previously considered to be the cause for trichophagia, as a form of pica syndrome, with subsequent bezoar formation. A plain radiograph will show a mottled pattern in the stomach similar to a food-filled stomach. An upper GI contrast study will confirm the diagnosis. Ultrasonographic diagnosis may be relatively specific. A broad band of high-amplitude echoes can be seen superficially, with complete sonic shadowing behind. Bezoars are removed surgically except for lactobezoars.