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Unusual cause of gastric outlet obstruction: giant gastric trichobezoar: a case report.
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PMID:  19087240     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Trichobezoars are caused by hair ingestion. The usual presentation of a trichobezoar is with early satiety and malnutrition. Obstructive symptoms and manifestations of gastric outlet obstruction may occur. The diagnosis may be suspected in young females with malnutrition, who have a history of trichophagia.
CASE PRESENTATION: We report a case of 12-year-old female admitted to the emergency room for abdominal pain. On physical examination, she was cachectic and an epigastric mass was palpated. An exploratory laparotomy was conducted. A giant trichobezoar was palpated in the stomach and was removed through an anterior gastrostomy.
CONCLUSION: There were no complications postoperatively and the patient was referred to a psychiatrist.
Authors:
Ibrahim Yetim; Orhan Veli Ozkan; Ersan Semerci; Recep Abanoz
Publication Detail:
Type:  Journal Article     Date:  2008-12-16
Journal Detail:
Title:  Cases journal     Volume:  1     ISSN:  1757-1626     ISO Abbreviation:  Cases J     Publication Date:  2008  
Date Detail:
Created Date:  2009-02-03     Completed Date:  2012-10-02     Revised Date:  2012-11-09    
Medline Journal Info:
Nlm Unique ID:  101474272     Medline TA:  Cases J     Country:  England    
Other Details:
Languages:  eng     Pagination:  399     Citation Subset:  -    
Affiliation:
Mustafa Kemal University, Faculty of Medicine, Department of General Surgery, Antakya/Hatay, Turkey. veliorhan@hotmail.com.
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Journal ID (nlm-ta): Cases J
ISSN: 1757-1626
Publisher: BioMed Central
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Copyright ? 2008 Yetim et al; licensee BioMed Central Ltd.
open-access: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Day: 12 Month: 11 Year: 2008
Accepted Day: 16 Month: 12 Year: 2008
collection publication date: Year: 2008
Electronic publication date: Day: 16 Month: 12 Year: 2008
Volume: 1First Page: 399 Last Page: 399
ID: 2634769
Publisher Id: 1757-1626-1-399
PubMed Id: 19087240
DOI: 10.1186/1757-1626-1-399

Unusual cause of gastric outlet obstruction: giant gastric trichobezoar: a case report
Ibrahim Yetim1 Email: yetim54@gmail.com
Orhan Veli Ozkan1 Email: veliorhan@hotmail.com
Ersan Semerci1 Email: ersemerci@yahoo.com
Recep Abanoz2 Email: drrecepabanoz@gmail.com
1Mustafa Kemal University, Faculty of Medicine, Department of General Surgery, Antakya/Hatay, Turkey
2Bafra State Hospital, Bafra/Samsun, Turkey

Background

Bezoars are incompletely digested food or fibrous materials that may cause intestinal obstruction over the time. Common clinical symptoms include abdominal pain, nausea, vomiting, weight loss [1]. Trichobezoars are seen in case of large amount of hair ingestion. Trichobezoars are more common in paediatric age than adults with up to 90% occurring in girls [2]. In this report, we describe a 12-year-old girl with obstructing trichobezoar of stomach and duodenum.


Case report

A 12 year old girl was admitted to our emergency department with 5 days history of abdominal pain and non-bilious vomiting. On physical examination, patient was cachectic and an epigastric mass was palpated. Biochemical results were normal except mild anaemia. X-ray depicted that stomach was dilated with no air-fluid level. Ultrasonography (USG) revealed hyperechoic mass on the epigastric region. On the computed tomography (CT) appearance, there was a heterogenous lesion from stomach to horizontal duodenal part that causes distation with circumcised air trapping (Figure 1). Patient had history of trichophagia for a long time. Patient underwent laparotomy. Upper midline incision was performed. A giant trichobezoar was removed through an anterior gastrostomy. This mass extended to proximal part of duodenum. The mass weighed 125 g and measured 8.5 ? 22 cm (figure 2). There was no complication postoperatively. Patient was discharged a week later.


Discussion

The term bezoar was derived from the Persian word 'panzeh' meaning 'antidote' [3]. In ancient times, bezoars were considered as a protection against poisoning. They are divided into three categories according to components; phytobezoars (plant material), trichobezoars (hair) and lactobezoars (milk) [4]. Phytobezoars are generally found in patients with history of gastric surgery. Lactobezoars are exclusively found in infants. Prematurity and concentrated formulas are leading causes of lactobezoars. Trichobezoars are caused by ingestion of high amount of hair over many years. They are formed typically in stomach and they may enlarge leading to gastric outlet obstruction [5,6] The cause of hair ingestion may be associated with mental retardation, pica or trichotillomania which is a behavioural disturbance characterized by the compulsive urge to pull one's hair and eat it. Up to 90% of all trichobezoars occur in girls younger than 20 years old [2]. Males are rarely affected. Trichobezoar have a special type called 'Rapunzel Syndrome'. In that syndrome gastric trichobezoars could have a long tail that can extent to ileoceal valve [7,8].

Common presenting symptoms are abdominal pain, nausea, vomiting, weight loss, malnutrition, hematemesis, diarrhoea or constipation. On physical examination epigastric mass may be palpated. Alopecia may also be present due to trichotillomania.

USG and CT imaging features are helpful in diagnosis. On the USG, bright echogenic band and shadow over the left upper quadrant may exist. CT demonstrates heterogenous, mottled intraluminal mass with low attenuation and air trapping [9].

Phytobezoars may be digested enzimatically but trichobezoars are generally resistant to that treatment. Small gastric bezoars can be removed endoscopically. Large gastric trichobezoars can be removed either endoscopically or by laparotomy. In our case, a giant bezoar had caused duodenal obstruction. Small intestinal obstruction is rare but small intestine examination is important for ensuring about any other mass remnant.

Since recurrences could occur, the patient must be directed to psychiatric follow-up after the operation.


Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor- in ? Chief of this Journal.


Competing interests

The authors declare that they have no competing interests.


Authors' contributions

IY and RA analysed and interpreted the patient data. OVO and ES performed the literature review, and was a major contributor in writing the manuscript. OVO and IY performed the final editing of the manuscript. All authors read and approved the final manuscript.


References
Hoover K,Piotrowski J,St Pierre K,Katz A,Goldstein AM. Simultaneous gastric and small intestinal trichobezoars ? a hairy problemJ Pediatr Surg 2006;41:1495–1497. [pmid: 16863865] [doi: 10.1016/j.jpedsurg.2006.04.003]
Lynch KA,Feola PG,Guenther E. Gastric trichobezoar: An important cause of abdominal pain presenting to the pediatric emergency departmentPediatr Emr Care 2003;19:343–347. [doi: 10.1097/01.pec.0000092581.40174.e3]
DuBose TM,Southgate WM,Hill JG. Lactobezoars: A patient series and literature reviewClin Pediatr 2001;40:603–606. [doi: 10.1177/000992280104001104]
Ratan SK,Grover SB. Giant rectosigmoid stone bezoar in a childClin Pediatr 2000;39:500–502. [doi: 10.1177/000992280003900815]
Kaplan M,Ozeri Y,Agranat A,Brisk R,Eylath U. Antacid bezoar in a premature infantAm J Perinatol 1995;12:98–99. [pmid: 7779206] [doi: 10.1055/s-2007-994414]
Tsou VM,Bishop PR,Nowicki MJ. Colonic sunflower seed bezoarPediatrics 1997;99:896–897. [pmid: 9164789] [doi: 10.1542/peds.99.6.896]
Kleiner O,Finaly R,Cohen Z. Giant gastric trichobezoar presenting as abdominal mass in a childActa Pediatr 2002;91:1273–1274. [doi: 10.1080/080352502320777612]
West WM,Duncan ND. CT appearances of the Rapunzel syndrome: An unusual form of bezoar and gastrointestinal obstructionPediatr Radiol 1998;28:315–316. [pmid: 9569269] [doi: 10.1007/s002470050362]
Newman B,Girdany BR. Gastric trichobezoars ? sonographic and computed tomographic appearancePediatr Radiol 1990;20:526–527. [pmid: 2216587] [doi: 10.1007/BF02011382]

Figures

[Figure ID: F1]
Figure 1 

Computed tomogram of the Abdomen. Trichobezoar seen on Stomach (?) and duodenum (?)



[Figure ID: F2]
Figure 2 

Trichobezoar extracted from stomach with an approximate length 22 cm (Black bar is shown approximately 5 cm length).



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