i;::~~~~~~ ~;~'~~JK SCIENCE

I CASE REPORT ITrichobezoars: Case Reports and

Review ofLiteratureRajinder Parshad, Srinivas Prabhu, G.V.R. Kumar, A. Mukherjee, D. Bhamrah

AbstractBczoars arc masses of foreign material in the gut, which can be of four types: phylObcl.oars.trichobczoars. lactobezoars and food boluses. Phytobezoars arc the commonest among lh~se.

Stomach is the commonest site for bezoar formation. Bezoars can result in obstruction. irritationand damage to the gastric wall and malnutrition. They may present to the clinician with the complaintsof pain abdomen, they may migrate into small intestine where they m3) calise obstruction orperforation, vomiting and malnourishment. Trichobezoars are associated with trichotillomania adisorder characterized by faillU'e to resist impulse to pull out ones hair. In this article we revie\\t\\O cases. first was a case of twenty eight year old female who was diagnosed as a case ofgastric trihobezoar and the second case was a thirty year old lady diagnosed as a case of perforationperitonitis due to trichobczoar in jejunum, with one part in the stomach.

Key words

Bczoars. Trichobczoars, Gut

Introduction

The tcrm bezoar refers to accumulationlimpaction of

foreign material in the gastrointestinal tract and is known

to occur in lllan and animals for centuries. Bczoars from

the intestine of animals were originally worn as charms

and promoted as remedies to prevent disease. Bezoars

were also ground into potions for use as antidotes; the

term bezoar comes from either the Arabic "badzclu·11 or

Persian Hpadzehr" or Hebrian l1beluzaarl1 which allmcans

antidote or counter poison( 1-4).

The first serious dissertations on the bezoar was made

by Imad ul oia as early in thc 16th century (I). During

the middle ages man) healing qualities were attributed

to bezoars. The earliest references on the subject "'·:as

made by Sushruta in India which dates back to 12th cen­

tUI)' BC(5).

In western countries, it was lirst dcscribcd b)

Baudamant at autopsy in 1779 (6). The first surgical

removal was done by Schonhorn in 1883 (6). Sincc Ihen

several case reports and small series have been reported

and a classic review of the topic (311 cases) "as made

by DeBakey and Ochsner in 1938(2). We report our ex­

perience with two such cases.

CASE-I

The patient SO. a twenty eight year old woman·

presented with complaints of buming pain epigastrium

and a lump in the upper abdomen raf three months. The

pain was severe, non-colicky. burning in nature had no

relation to meals and had no relieving or aggravating

factors. She also complaincd of early satiety and occa­

sional vomiting. She had no bowel complaints. She was

From the Department ofSurgical Disciplines, All India Institutc or Medical Sciences. New Delhi, IndiaCorrespondence fa: Dr. Rajindcr Parshad. Associate Professor. Department ofSurgical Discipline. AIIMS. Ne\'.. Delhi.

102 Vol. 4 No. 4. Octobcr~Dccell1bcr2002

_____________J~.:K SCiENCE

malTied for the past nine years and had an eight year old

daughter. subsequently shc had four first trimester

ab0l1ions. There was no rustory of hair pulling or hair

eating. although she had a habit ofholding her hair in her

mouth. She had long hair and her frontal hair appeared to

be irregular. suggesting the possibility ofhair pulling. A

psychological evaluation revealed minor depressive

disorder without any obessive component.

On examination of the abdomen a 6 x 8 centimeter

mobile. firm. non-tender epigastric mass was palpable.

Routine blood investigations were within nonl1al limits.

Barium meal examination and upper gastrointestinal

endoscopy was perfonned. These evaluations revealed

Ihe presence of a gastric trichobezoar (Fig. I).

Fig J. Harium meal c\:lminaliol1 sho\\ing gastric tnchobezoar.

She was taken up for exploratory laparotomy. The

abdomen was explored via a midline incision. The

IIichobezoar was removed via a gastrotomy, which was

closed in two layers. Her postoperative course was

une,·entful. Aller discharge she was referred for a psychi­

atric follow up and at the time ofwriting this paper she was

being investigated for the cause ofthe multiple abortions.

CASE REPORT-2

LK. a 30 year old woman was admi tred wi th history

l,fmid abdominal pain for 20 days. The pain was initially

colicky but became continuous two days prior to the

admission. There was history of bilious vomiting. The

patient had passed small amount of flatus and stools till a

day prior to the admission. She had been suffering from

intestinal colic for one year prior to this episode. Patient

Vol. -4 No.4. OClober·December 2002

had history ofpica, which was revealed by the paticnt's

mother. History of eating her own hair in childhood,

episode of pain abdomeJ. with reClIlTent vomiting and

presence of hair strands in the vomitus was rcvealed by

patient's mother. There was no history ofany past surgical

treatment. On examination the paticnt was afebrilc but

dehydrated and having tachycardia (1IR-120/mt). Abdo­

men was tender and bowel sounds \\cre diminished but

abdomen was not grossly distended. Rectal examination

revealed an empty rectum.

Laboratory investigations showcd mild anemia (lib

I 1gm%). nonnal white blood ccll COll1lt (4300/mm). blood

urea 56mg% and scrum elcclrolytcs Na+ -152me'l/!. K+

-3.1 me'l/l, levels consistent \\ith dehydration. Barium meal

follow through cxamination donc one week prior to

admission in another hospital revcalcd a persistent honey­

comb barium coated mass in thc proximal small bowcl.

Plain x-rays done in the emcrgency department ofAIIMS

also showed a persistent honey comb mass with rctained

barium in the proximal small bowel and stomach with

pneumopcritonewn. However rest of the bowel was not

distended and therc werc no air fluid lc' cis. (Fig. 2)

Fig 2. Ahdominal radiograph shm\ Ing persistent harium l'oatedhoneycomb mass in (he stomach and small huwel.

An exloratory laparotomy was performed. On

exploration there was generalised perotonitis as well as

a loculated collection just below transverse mesocolon.

203

\ ~JK....S;;;,C;;;.;,;IE~N.;,C;;;;,;;;E _----------------Q.,.~.-

Bo\\"cl cxamination re"ealed two perforations (each of

2cm diameter) \\ ith unhealthy margin at the duodeno

jejlUlaljlUlction with proximal end oflhe trichobezoar pro­

jecting through thc pcrforatins. Trichobezoar (30 cm in

length) \\as remO\ cd through the perforations which were

closed primarih (hg.:1l,

Fig J. IrichOl)cJ;Uar~ l':\ I r;14.:t~d from ~IOIll<H:h tupperJand smallintesline(lowcr).

!\ duodenojejuonostomy with 2nd part ofduodenum was

done to bypass the unhealthy duodenal jejunal junction area.

Examination of stomach revealed another trichobezoar 10­J:2 em soft indclltable mass which was removed through a

gastrotomy. Rest of the bowel ,",vas normal.

Postoperatively. patient developed listula from the site

of perforation closure which WllS mllnaged non-operatively

and patient was discharged on 23 post operative day when

the listula healed completely. Psychiatric evaluation did

not reveal any major psychological problem.

Discussion

Classification: Based on the origin there are four classesof bezoars: phytobezoars. trichobezoars, lactobezoars and

medication or food bolus bezollrs (4.7).

Trichobezoms were once the 1110st common types ofbezoars and accounted for more than half of the 303 cases

collected by DeBakey and Ochsner in 1938(2).

Characteristically, trichobezoars occur in children and ado­lescent females with long hair and emotional disturbance

associated with trichotillomania or tichophagia (8,9).

Clinicill presentation

More than 90% are reported in females with peak

incidence in the second and third decades (10). These

patients may ingest not only their hair, but also from other

204

persons and animals as well as fibres from carpets andother sources(3). Evidence of hair loss may be present.

There is controversy over the incidence of underlyingpsychological disturbances in these patients.

Trichobezoars are fomled and usually confined to stomach

and symptoms develop gradually as the bczoars grO\\. Initially

patients may have anorexia. nausea and vomiting. early satiety.weight loss. epigastric pain and abdominal discomfort relatedto meals. Later patients ma) develop features ofgastric outletobstruction with passage of hair fragments in vomitus(3,11.12). Symptoms may be intermittent.

Sometimes trichobezoars may extend beyond the pylorus

or may dislodge and travel into the small intcstine wherethey may cause complicatiolns (12). Rapuni'cl syndromeoccurs when intestinal obstruction is produced by atrichobezoars with a tail that extends to or beyond ileocaecalvalvde (3,11,12,13).

Examination sometimes reveals hair loss. halitosis orepigastric mass which is mobile in all directions. Crepitusover the lump and indentability have been reported asspecific signs oftriehobezoars (10). Ilair in the vomitus or

gastric aspirate is diagnostic.

LahoratolY investignations usually reveal an iron deficiency.microcytic. hypochromic anemia, slight leucocytosis and apositive test for occult blood. Radiologiclll examination helps inmore than 70% cases. Plain abdominal radiographs may behelpful in a few cases but barium meal or cndoscopy arc usually

necessaJ) to conCinll the diagnosis. Barium meal may show anintragastric mass with barium retained on its honeycombsurface. Gastric endoscopy has becn shovvn to be the diagnostictechnique of choice (6,7,14) and it also has therapeutic value.

Bezoars appear as a rnllss ,>ViUl a highly echogenic surr.1ce on

ultrasound with minimal distal transmission; a mesh like pattern

may be seen on CTscan. and a mass "'Ul signal density similar

to air is seen on MRI (15,16).

Surgical removal remains the main stay of treatment ofbezoars. As in our patient this was the mode of removal andthis was successfully achieved with minimal morbidity.Removal ofbezoars by endoscopy requires multiple insertionsof the scope, removal of the bezoars piecemeal and a 101 of

patience and timet 17). To aid endoscopic removal enzymatic

digestion by proteolytic enzymes has been tried. -n,e actual

Vol. 4 o. 4. October-December 2002

, .,JK SCIE 'CE

-----------Q-~

disintegrmion may be achieved via a water jet, Nd: YAG

laser or mechanical disimpaction( 18). Chemical dissolution

of trichobczoars have been attempted with instillation of

papain and sodium bicarbonate. The problems with this mode

of therapy include a low success rate. derangement of acidbase balance and cven possible monality(3),

Complications

These include anorexia. hcmatemesis, gastric wall,

Ulceration and hee perforation with peritonitis(l 0), Other

conrp'l)\:.'3\\ons arc intestinal obstruction, obstructive

jaundice. malabsorption. protein loosing enteropathy.

tnlUssesception and append icitis (2,3,6, 11.12, 13), In the

most thorough review to date by DeBakey and Ochsner in

1938, the incidence of small bowel obstruction due to

trichobezoar was 10,8% (27% with phytobezoar), The

overall mortality rate was 19,1% with trichobezoar while

in case of small bowel obstruction mortality rates rose to

47%, Drugs ma) get entrapped in bezoar and result in de­

la)ed reiease, which can precipitate toxicity (18),

Summar)

Although known for centuries, bezoars continue to

present diagnostic and therapeutic challenges for the

surgeon, Bezoars have become increasingly recognized as

a cause of intestinal obstruction. The current treatment

and long term management depend upon identification of

the nature and knowledge of the pathophysiology of each

beloa", Bezoars should preferably be recognised prior to

the development of perforation and peritonitis and treated

appropriatcly to minimise morbidity and mortality. Most

attcmpts at endoscopic removal oftrichobezoars have failed

and hence the preferred treatment is surgical, If feasible,

the bezoar mal be removed through a single enterotomy,

Ilo\\'cver. if there is evidence of mesenteric necrosis or

scaled off perforations, it is suggested that multiple

enterotomies be used to reduce tension placed in mesenteric

border \\hen removing the mass (12, 13), After removal,

ofthe bezoar rest of the bowel should be carefully examined

for all) missed perforation or residual bezoar.

Psychiatric evaluation is essential to prevent recurrence

as underlying psychological and emotional disturbance may

be a factor in trichophagia or trichotillomania,

Vol. 4 No. 4. October~Decell\ber 2002

Rcfucnccs

I. Eigood C. A treatise on the bezoar stone. AI/II ,Hed IIjs~

lory 1935;7:73-80,

2. DeBakey M. Ochsner A. Bczoars and concretions.Surgery 1938:4:934~63.

3. Deslypere JP. Pract M. Verdonk G. An unusual case oftrichobezoar: The Rapul1zel syndrome. /11/ J(iasfroell(el'ul 1982;77( 7):467-70.

4. Goldstein SS. Lewis JM. Rothstein R. Intestinalobstruction due to bezoars. Alii .J Gaslroenlel'o! 1984 :79(4): 3t3-18,

5. Lall MM. Ohall Jc. Trichobezoar: a colleclin analysisof 39 cases from India with a case report. Ind P{led

t975: t2:351-53.6. Rees M. Intussusception caused by multiple tricho­

bezoars: a surgical trap for the unwary. HI' J Sill:!.!. 198-l:71:72L

7. Andrus C H. Ponsky JL. Bezoars:cIassification. p<lthophysi~

ology and treatment. Am J GasferelJlero/1989;83(5 }-l76~78.

8. Assevero VL. Brooks DA. Cardaze W W. el a/. Trichobeloaras an expression ofemolional disturbance.. Jill J f)/s Childt957;94:668-671,

9. Drel'..nik Z. Wolfstcin I, Avigad I el 01. 1i·;chohe:oar.,· 1111Surg t976;6t:219-2L

10. Lamerton A J. Trichobezoar: Tvm case reports; A newphysical sign. Am J Gmll'oenfcl'O/ 1984: 71 (5 ):35-l~56.

11. Wolfson Pl. Fabius RJ. Leibowith AN. The Rapullzclsyndrome: An unusual trichobezoar. ....1111 J (imlroe/llerol

1987;82(4)365-6 7,

12. Dalshauy GB. Wainer S. hol1aar G.L. The Rapunzel Syn­drome (Trichobezoar) causing atypical intussesceptioll in achild: A case repon. J Paee/jall' Surf!, I999:3-1(3)-l79-80.

13. Vaughan ED Jr.. Sawyess JI. Scott HW Jr. The Rapullzelsyndrome: An unuslwl complication or intestinal bCloar.Surgery t968;63(~ )339-43,

1-1. Bhukhanwala F A. Kcthe NV. Asgaonkar DS. Duodenaltrichobezoar prescnting as intcstinal obstruction. J rlSSO.'

Physc Iud t996;44( t0)725-26,

15. West WM. Duncan D. CT appearances of the RapunzclSyndrome: An unusual form of bezoar and gastrointestinalobstruction. Paedjalr Radio!1998:28:315~16.

16. Sinzig M. Werner H. Hasselbach H. el 0/. Gastrictrichobezoar with gastic ulcer. MR findings. Paediafr Radiolt998:28:296,

17. GOSSUIll AY. Dclhaye M. Cremer M. Failure of non surgicalprocedures to treat gastric trichobczoar. L'ndoH:oP.\t989:2t:t t3,

18. Thomley-Brown D. Galla J IL Williams P D el al. Lithiumtoxicity associated with a trichobezoar. AfI" In' Afed

t992; t t6(9) 739-40,

205