20-year-old female patient who presented at the casualty department with fullness in her left lower quadrant. Ultrasound showed a distended stomach. Further questioning revealed a history of trichophagia. Abdominal radiograph and CT confirmed the presence of a large trichobezoar with a distended stomach reaching the pelvis.
Initial imaging by ultrasound showed a distended stomach. This prompted further investigation. A plain abdominal radiography showed central and left sided paucity of bowel gas shadows. This was highly suggestive of a large abdominal mass. CT showed a distended stomach, reaching the true pelvis. The stomach was being distended by a large mass which was composed of striated material arranged in a helical pattern. Given the clinical history of prolonged trichophagia, this was in keeping with a large trichobezoar. Review of a frontal chest radiograph performed two years prior to this episode, when the patient presented with prolonged nausea and vomiting, showed that the trichobezoar was already present at the time. This is seen as a curvilinear shadow just below the gastric air bubble. The patient did not admit to having prolonged trichophagia at the time, and no further investigation was performed since her condition improved with conservative measures.
A bezoar is an intraluminal mass formed by the accumulation of indigestible material in the gastrointestinal tract. It can be compoased of hair (trichobezoar), vegetables (phytobezoar), milk (lactobezoar), medications (pharmacobezoar), or of a combination of the latter (for example phytotrichobezoar) .
Trichobezoars have been described in the literature as comprising 55% of all bezoars .
Human hair is resistant to digestion and peristalsis. Over a period of time, continuous ingestion of hair leads to accumulation in the stomach, with resultant formation of a ‘mass’ of hair (trichobezoar). Trichobezoars are usually located in the stomach but strands of hair might extend from the pylorus into the duodenum and small bowel (Rapunzel syndrome) .
This condition is typically seen in children or female patients especially in psychologically, emotionally and mentally disturbed patients. These patients have an irrational strong urge to pull their hair (trichotillomania – hair-pulling disorder) and swallow it (trichophagia) .
Trichobezoar is often missed in its early stages due to non-specific or even lack of symptoms. The symptomtomatology is related to the mass effect caused by gradual increase in size of the trichobezoar, and includes non-specific abdominal pain, weight loss, poor appetite, nausea and vomiting. Malnutrition is a frequent association and a protein losing gastroenteropathy has been described. Complications of bezoars include gastric mucosal ulceration, perforation, intussusception and obstruction. On examination a mobile abdominal mass may be felt in the epigastrium and area of alopecia circumscripta may be evident.
The diagnosis of a gastric trichobezoar can be confirmed by radiography or endoscopy. Pre-operative diagnosis is usually made by ultrasound and confirmed by CT. Plain abdominal radiography might show a grossly enlarged stomach, with consequent peripheral displacement of bowel loops, or else a gastric outlet obstruction. Upper gastrointestinal barium studies might delineate a mass confirming to the gastric contour. Ultrasound usually shows a distended stomach containing bright echogenic material, but may be of limited use if gas is anterior to the trichobezoar. CT shows an intraluminal, heterogenous, hypodense non enhancing mass composed of striated material.
Surgery is often the only definite treatment, due to the large size of most trichobezoars at diagnosis. Even if surgery is contemplated, endoscopy might be still used to confirm the composition of the bezoar. Bezoars can be occasionally removed endoscopically, if small. A full psychiatric workup should be always resorted to, in order to prevent recurrence.
Differential Diagnosis List