Transient pancreatitis and small bowel obstruction by trichobezoar.
|Article Type:||Case study|
CT imaging (Health aspects)
Pancreatitis (Risk factors)
Pancreatitis (Care and treatment)
Pancreatitis (Patient outcomes)
Pancreatitis (Case studies)
Intestines (Risk factors)
Intestines (Care and treatment)
Intestines (Patient outcomes)
Intestines (Case studies)
|Publication:||Name: Applied Radiology Publisher: Anderson Publishing Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Anderson Publishing Ltd. ISSN: 0160-9963|
|Issue:||Date: Jan, 2011 Source Volume: 40 Source Issue: 1|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
A 14-year-old girl with no significant medical history complained of worsening epigastric abdominal pain, nausea, and vomiting of several days duration. The patient had epigastric tenderness, but no peritoneal signs, and her examination was otherwise unremarkable. At admission, the only abnormal laboratory values were elevated amylase and lipase consistent with acute pancreatitis. With supportive care, the patient's laboratory abnormalities returned to normal over the course of 2 days, but her symptoms worsened and she began to have high-output bilious drainage from a nasogastric tube.
A scout view of the abdomen revealed a single prominent segment of small bowel in the upper abdomen, but no other abnormalities (Figure 1A). Delayed overhead images from an upper gastrointestinal (GI) series demonstrated a dilated proximal jejunum and multiple ovoid filling defects occluding the bowel lumen (Figure 1B). The most distal of the filling defects appeared to have a thin barium tail extending into the distal bowel. Further delayed images showed no passage of contrast beyond the filling defects.
Transient pancreatitis and small bowel obstruction by trichobezoar
[FIGURE 1 OMITTED]
Trichophagia is not uncommon in the pediatric population but when severe it may lead to trichobezoar formation. It occurs most often in young females and in patients with psychiatric disorders. (1)
Trichobezoars form in the stomach where hair is trapped proximal to the pylorus. Aggregated mats of hair subsequently conform to the gastric contours and may eventually cause vague abdominal pain, gastric outlet obstruction, ulceration, or perforation. (1,2) They can also grow to massive proportions, filling the gastric lumen and presenting as large abdominal masses. (3) Occasionally, trichobezoars form tails that extend through the pylorus. In rare cases, these tails extend as far as the terminal ileum and may cause small bowel obstruction, a complication known as Rapunzel syndrome. (4) Although they usually remain in the stomach, a small trichobezoar or fragments of a larger trichobezoar may migrate into the small bowel, causing obstruction (Figure 2). (2,5) Given the diversity of possible complications, the presentation of trichobezoar can be quite variable ranging from asymptomatic abdominal mass or vague abdominal pain to obstructive symptoms or acute abdomen.
[FIGURE 2 OMITTED]
Pancreatitis is a rare presentation. We identified a small number of published reports of this bezoar complication. (9,10,11) Pancreatitis may occur when the tail of a gastric bezoar extends into the duodenum leading to ampullary irritation and obstruction. In the present case, transient pancreatitis was likely the result of irritation of the ampulla by the bezoar as it passed in its entirety through the duodenum. Improvement in amylase and lipase levels occurred as the bezoar continued into the jejunum, where it caused small bowel obstruction.
Trichobezoars are a relatively rare entity that may have a protean presentation. In the pediatric population, it can be considered in the differential diagnosis for any patient with an abdominal mass, vague abdominal pain, obstructive symptoms, or an acute abdomen.
[FIGURE 3 OMITTED]
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(3.) Ciampa A, Moore BE, Listerud RG, Kydd D, et al. Giant trichophytobezoar in a pediatric patient with trichotillomania. Pediatr Radiol. 2003;33:219-220.
(4.) West WM, Duncan ND. CT appearances of the Rapunzel syndrome: An unusual form of bezoar and gastrointestinal obstruction. Pediatr Radiol. 1998;28:315-316.
(5.) Krol CM, Karol I, Khalil H, Shah S. Small-bowel obstruction due to migratory trichobezoar in a child: CT diagnosis. AJR Am J Roentgenol. 2001;177:255-256.
(6.) Gayer G, Jonas T, Apter S, et al. Bezoars in the stomach and small bowel--CT appearance. Clin Radiol. 1999;54:228-232.
(7.) Silverman FN, Kuhn JP. Caffey's pediatric x-ray diagnosis: An integrated imaging approach. 9thed. Mosby. 1993;1052.
(8.) Newman B, Girdany BR. Gastric trichobezoars--onographic and computed tomographic appearance. Pediatr Radiol. 1990;20:526-527.
(9.) Shawis RN, Doig CM. Gastric trichobezoar associated with transient pancreatitis. Arch Dis Child. 1984;59:994-995.
(10.) Mekisic A, Farmer E. Trichobezoars. Aust N Z J Surg. 1994;64;281-283.
(11.) Katapadi M, Kostandy G, Wang A, et al. Can a bezoar cause acute pancreatitis? J Clin Gastroenterol. 1997;24:120-121.
David Weeks, MD
Prepared by David Weeks, MD, while at the Department of Radiology, Westchester Medical Center, Valhalla, NY.
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