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Pediatric surgical image

Simultaneous gastric and small intestinaltrichobezoars—a hairy problem

Kevin Hoovera, Julie Piotrowskib, Kristin St. Pierreb,Aubrey Katzc, Allan M. Goldsteinb,*

aDepartment of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USAbDepartment of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USAcDepartment of Pediatric Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston,

MA 02114, USA

0022-3468/$ – see front matter D 2006

doi:10.1016/j.jpedsurg.2006.04.003

* Corresponding author. Tel.: +1 6

2167.

E-mail address: agoldstein@partners

Index words:Trichobezoar;

Gastric outlet obstruction;

Small bowel obstruction

Abstract A trichobezoar represents a mass of accumulated hair within the gastrointestinal tract.

Isolated gastric trichobezoars, those with extension into the duodenum, and small intestinal

trichobezoars have all been described. However, the presence of discrete gastric and intestinal

trichobezoars has been rarely presented in the literature. This case report describes synchronous

trichobezoars in the stomach and jejunum in a 9-year-old girl presenting with abdominal pain,

anorexia, and vomiting. This case emphasizes the role of radiographic imaging in the diagnosis of

trichobezoars and the importance of a complete clinical evaluation of the small bowel at the time of

removal of an obstructing gastric bezoar.

D 2006 Elsevier Inc. All rights reserved.

Trichobezoars usually occur in patients who have

trichotillomania, a behavioral disorder characterized by the

compulsive urge to pull one’s hair, combined with tricho-

phagia, the ingestion of that hair. Trichobezoars typically

occur in the stomach and present with abdominal pain,

anorexia, and vomiting. As they enlarge, they can produce

gastric outlet obstruction, bleeding, and perforation. In rare

instances, trichobezoars can also cause small bowel obstruc-

tion. In this report, we describe a 9-year-old girl who

developed obstructing trichobezoars of both the stomach and

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17 726 0270; fax: +1 617 726

.org (A.M. Goldstein).

small intestine and review the clinical presentation, radio-

graphic findings, and surgical management.

1. Case report

A 9-year-old girl presented with a 2-week history of

worsening crampy abdominal pain. Four days before

admission she developed nonbloody, nonbilious emesis

associated with anorexia. Initially, only solid foods

precipitated vomiting, but the day before admission she

could not keep down liquids. She denied fever and had a

normal bowel movement 2 days before admission. In the

emergency department, she complained of diffuse abdom-

inal pain, particularly when lying supine. Her medical

Journal of Pediatric Surgery (2006) 41, 1495–1497

Fig. 1 Ultrasound and CT of gastric trichobezoar. A, Ultrasound of the abdomen demonstrates shadowing of the left upper quadrant by a

gastric mass (asterisk). B, Axial CT image shows a heterogeneous mass within the stomach, partly surrounded by contrast. GB indicates

gallbladder; B, bezoar.

Fig. 2 Gastric trichobezoar. Large trichobezoar (12.5 � 8.2 �3.9 cm) removed from stomach. Ruler shown is 15 cm in length.

K. Hoover et al.1496

history was notable for trichophagia at 4 years of age,

which her parents felt had been resolved. She had no other

medical history and was not on any medications. Her

social development and school performance were both

unremarkable. On physical examination there was no

evidence of hair loss from the scalp. Her abdomen was

notable for a moderately tender, firm mass in the mid-

epigastrium. Laboratory studies were unremarkable.

Ultrasound of the abdomen identified an echogenic mass

within the stomach shadowing the left upper quadrant

(Fig. 1A). Abdominal computed tomography (CT) demons-

trated a heterogeneous mass within the stomach partially

surrounded by oral contrast, consistent with a bezoar

(Fig. 1B). No evidence for small or large bowel obstruc-

tion was identified.

The child was brought to the operating room where

upper endoscopy was performed, demonstrating a large

gastric trichobezoar extending through and obstructing the

pylorus. The mass was too large to be removed endoscop-

ically and an upper midline incision was made. A large

trichobezoar was removed through a transverse gastrotomy.

The mass weighed 96.9 g and measured 12.5 � 8.2 � 3.9

cm (Fig. 2). The proximal small bowel was inspected and

found to be decompressed and without palpable masses.

The patient initially did well, but developed vomiting and

distention on postoperative day 4. An abdominal x-ray was

consistent with a small bowel obstruction. Abdominal CT

scan showed dilated small bowel to the level of the mid-

jejunum, where a bubbly-appearing intraluminal mass was

identified (Fig. 3A). In retrospect, this mass was present,

although not obstructing, on the admission CT scan.

Laparotomy was performed and an obstructing trichobe-

zoar, measuring 4.5 � 2.3 � 2.0 cm, removed from the

small intestine, 1 m distal to the pylorus (Fig. 3B). The

child was discharged home 1 week later. She was seen in

consultation with a child psychiatrist, but the parents have

repeatedly refused outpatient treatment.

2. Discussion

Trichobezoars form after the ingestion of large amounts

of hair, often over many years. In a large review, DeBakey

and Ochsner [1] found that 80% of patients were younger

than 30 years and more than 90% were female. The

underlying psychiatric disorder in many of these patients is

trichotillomania, an irresistible urge to pull one’s hair.

Although trichotillomania affects about 1% of the popu-

lation, only one third have trichophagia, and just 1% of

those individuals eat enough hair to require surgical

intervention [2]. Trichobezoars are therefore quite uncom-

mon in clinical practice.

Most trichobezoars are found within the stomach [1],

where they typically produce epigastric pain, nausea,

vomiting, and anorexia [3,4]. As the mass enlarges from

additional hair or trapping of ingested food particles, gastric

outlet obstruction ensues [5]. Rapunzel syndrome refers to

an uncommon condition in which a long btailQ of hair

extends from the stomach into the small intestine, or from

the small intestine to the colon [2,5,6]. Small bowel

obstruction from a trichobezoar is rare [6-8], accounting

for only 10% of cases [6]. The presence of simultaneous

gastric and small intestinal bezoars has been reported [3,9].

Fig. 3 Small intestinal trichobezoar. A, Computed topographic image shows a small bowel (SB) obstruction with a mottled intraluminal

mass (arrow) at the transition point. B, Trichobezoar (4.5 � 2.3 � 2.0 cm) removed from small intestine.

Simultaneous gastric and small intestinal trichobezoars—a hairy problem 1497

Characteristic imaging findings are helpful in diagnosing

trichobezoars. On conventional radiography these masses

may appear as a mottled soft tissue opacity in the shape of

the distended stomach [10]. A calcified rim may delineate

the edge of the bezoar [9]. Upper gastrointestinal series may

demonstrate a large filling defect in the stomach, occasion-

ally extending into the small bowel. On ultrasound, a

trichobezoar typically appears as a curvilinear, bright

echogenic band which blocks transmission of sound waves,

casting a shadow over the left upper quadrant, as demon-

strated in this case (Fig. 1A) [11,12]. This results from the

high echogenicity of hair and the presence of multiple

acoustic interfaces created by trapped air and food [13].

Computed tomography characteristically demonstrates a

large, heterogeneous, mottled, mesh-like intraluminal mass

of low attenuation, which can contain trapped air [14].

When the mass is not completely obstructing, contrast

material can delineate the outer surface. Small bowel

obstruction from a trichobezoar can present as a well-

defined intraluminal mass with a mottled gas pattern at the

site of obstruction [15], as shown in Fig. 3A. Gastric

bezoars are difficult to characterize on magnetic resonance

imaging because of their characteristic low signal on all

sequences and may be confused with air [11].

Trichobezoars are generally resistant to enzymatic degra-

dation, unlike phytobezoars, which are composed of

vegetable matter. Removal of small gastric masses can be

attempted endoscopically, often assisted by mechanical

fragmentation [16]. Larger gastric trichobezoars must be

removed either laparoscopically or by laparotomy [17].

Despite the rarity of obstructing small intestinal trichobe-

zoars, this case illustrates the importance of examining the

entire length of the small intestine when removing a gastric

bezoar to ensure that no other mass is overlooked. Most

importantly, although surgery addresses the immediate issue,

psychiatric follow-up is essential to prevent recurrences [2].

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