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Gastric Trichobezoar: Case Report and Literature Review

1998; Elsevier BV; Volume: 73; Issue: 7 Linguagem: Inglês

10.1016/s0025-6196(11)64889-1

1942-5546

Michael R. Phillips, Salman Zaheer, George T. Drugas,

Foreign Body Medical Cases

Bezoars are conglomerates of food or fiber in the alimentary tract of humans and certain animals, mainly ruminants. In adults, bezoars are most frequently encountered after a gastric operation, but in children, bezoars are asso ciated with pica, mental retardation, and coexistent psy chiatric pathologic disorders. We describe a 4-year-old girl with trichotillomania in whom a gastric trichobezoar resulted in failure to gain weight, iron deficiency anemia, and a painless epigastric mass. The causes of gastric bezoars are discussed, with emphasis on diagnostic considerations, treatment options, and preventive measures. Bezoars are conglomerates of food or fiber in the alimentary tract of humans and certain animals, mainly ruminants. In adults, bezoars are most frequently encountered after a gastric operation, but in children, bezoars are asso ciated with pica, mental retardation, and coexistent psy chiatric pathologic disorders. We describe a 4-year-old girl with trichotillomania in whom a gastric trichobezoar resulted in failure to gain weight, iron deficiency anemia, and a painless epigastric mass. The causes of gastric bezoars are discussed, with emphasis on diagnostic considerations, treatment options, and preventive measures. Bezoars are foreign bodies in the gastrointestinal tract that increase in size by the accretion of nonabsorbable food or fibers. Interestingly, the term “bezoar” is derived from Arabic badzehr or from Persian panzehr, both meaning counterpoison or antidote.1Wlllial MRS The fasc inating history of bezoars.Med J Aust. 1986; 145: 613-614PubMed Google Scholar, 2Slen BJ Hunt RH Aezoers.in: Sleisinger MH Fofdtran JS Gastroint est inal Disease; Pathophysiology/ Diagnosis / Management. 5th ed. Saunders, Philadelphia1993: 758-763Google Scholar Bezoars are commonly found in domestic animals, and for centuries were used as charms or emollients to treat maladies as diverse as vertigo, epilepsy, and leprosy. Although the prevalence of bezoars in humans is low, if treatment is not administered, associated mortality rates may be as high as 30% primarily because of gastrointestinal bleeding, destruction, or perforation.1Wlllial MRS The fasc inating history of bezoars.Med J Aust. 1986; 145: 613-614PubMed Google Scholar The first description of a postmortem human be zoar was by Swain in 1854.3Chlholm EM Leong HT Chuna SCUAK Phytobezoar: an uncommon cause of small bowel obstruction.Ann R Calf Surt Engl. 1992; 74: 342-344PubMed Google Scholar The pathologic report of bezoars in humans was largely unrecognized, however, until 1939, when DeBakey and Ochsner4DeBakey M Ochsner A Bezoars and concret ions: a comprehensive review of the l iterature with analysis of 303 collected cases and a presentation of 8 additional cases.Surgery. 1939; 5: 132-160sGoogle Scholar reported 311 cases. Formed from persistent concretions, bezoars usually originate in the stomach and may consist of vegetable fibers (phytobezoar), hair (trichobezoar), persimmons (disopyrobezoar), or inspissated milk or formula (lacto bezoar). Bezoars most often develop after gastric operations that alter the motility, emptying, and grinding of food in the stomach. Trichobezoars are most common in children and adolescents with normal gastrointestinal function and usually result from an underlying behavioral disorder. This report describes a trichobezoar in a 4-year-old girl and highlights the salient features of diagnosis, treatment, and prognosis. A 4-year-old girl who weighed 18 kg was brought to the Mayo Eugenio Litta Children's Hospital because of fever and an upper abdominal mass, which had been detected by her mother. The mother reported that the child had experienced early satiety and poor weight gain for several months. The child had no history of nausea, vomiting, or change in bowel habit. Two days before admission of the child, otitis media had been diagnosed, and a 10-day course of amoxicillin had been prescribed. Three weeks before admission, she had been treated empirically with Pediazole for clinically suspected pneumonia, but her nonproductive cough had failed to resolve. She had no history of night sweats, dysuria, gross hematuria, or recent travel. In addition, she had no drug allergies and had not undergone an operation. From age 2 years up to 6 months before admission, the child was found infrequently to have ingested hair from brushes and packing from stuffed animals. Her mother denied that the child had any history of pica or ingestion of lead paint chips. As a small toddler, she was frequently noted to twirl her hair over her fingers to the extent of creating bald patches over the scalp and would eat her own hair. In fact, her hair had been shaved to thwart this behavior. Physical examination was notable for a playful preschooler with an oral temperature of 38.8°C, pulse rate of 138 beats/min, and respiratory rate of 28/min. Her conjunctiva and skin were pale; she had no evidence of icterus. Peripheral pulses were symmetric; skin turgor exhibited no tenting. Examination of her head and neck revealed only minimal erythema of the right tympanic membrane and no cervical lymphadenopathy. Chest and cardiac findings were unremarkable. The abdomen was soft and non tender with a firm, noncompressible mass in the epigastrium that was smoothly contoured, mobile, and nontender. No focal neurologic deficits were apparent. Laboratory test results were notable for a hemoglobin concentration of 7.5 g/dL, leukocyte count of 7 × 109/L, and platelet count of 505 × 109/L. Electrolytes, amylase, and liver function test results were normal. Erythrocyte morphology was consistent with severe microcytic hypochromic anemia. The serum iron level was 8 mg/dL, total iron binding capacity was 282 mg/dl., and ferritin was 8 mg/dL. Abdominal roentgenography demonstrated a prominent gastric outline with tiny calcifications just to the right of the first lumbar vertebral body (Fig. 1). A normal bowel gas pattern was apparent. A computed tomographic scan of the abdomen revealed a large, free-floating solid mass in a moderately distended stomach (Fig. 2). The mass. filled the gastric fundus and antrum and extended into the duodenum.Fig. 2Abdominal computed tomography with use of orally administered contrast medium, revealing free-floating mass confined within gastric lumen.View Large Image Figure ViewerDownload (PPT) A gastric bezoar was diagnosed, and a pediatric endoscopist was consulted. In light of the large size of the mass and the extent of calcification noted on the computed tomographic scan and abdominal roentgenograms, it was thought that endoscopy would likely fail to remove the mass completely without large fragmentation and the potential for distal intestinal obstruction. Thus, the patient was referred for surgical evaluation. An exploratory laparotomy through an upper midline abdominal incision was performed. At operation, an intraluminal, smoothly contoured mass was found occupying the bulk of the stomach and duodenal sweep and extending to the ligament of Treitz. The rest of the abdominal viscera was unremarkable. A longitudinal 5-cm gastrotomy was made on the anterior surface of the cardia of the stomach, and a contiguous trichobezoar cast of the stomach and duodenum was extracted (Fig. 3). The gastrotomy was closed in two layers. The child's recovery was complicated by pneumonia in the upper lobe of her right lung, which cleared with antibiotics and chest physiotherapy. Oral feeding with iron supplementation was initiated on the third postoperative day after a limited upper gastrointestinal contrast study excluded a gastric suture line leak. Before the child was dismissed, pediatric psychiatric consultation was sought to formulate long-term treatment planning, including play therapy and behavioral modification. Bezoars develop after ingestion of foreign material that accumulates in the gastrointestinal tract because of large particle size, indigestibility, gastric outlet obstruction, or intestinal stasis. Three types of bezoars are known to cause gastric outlet obstruction: phytobezoars, trichobezoars, and lactobezoars, which are unique to neonates. Phytobezoars are the most common and consist of undigested cellulose, lignin, hemicellulose, and fruit tannins derived from fruit and vegetable matter. They are most often seen in patients with a previous history of a gastric operation and are detected in up to 20% of patients who have undergone antrectomy.5Wang PY Skarsgald ED Baker RJ Carpet bezoar obstruction of the small intes tine.J Pedlatr Surg. 1996; 31: 1691-1693Abstract Full Text PDF PubMed Scopus (24) Google Scholar Reduction of gastric acidity, peptic activity, poor gastric mixing, and delayed emptying have all been implicated as contributory factors to the formation of phytobezoars.6Escamilla C Roblecampos R Parrllla-Paricio P LuJan-Mompean J Llron-Rulz R Toall Martlnez JA Intestinal obstruction and bezcers.J Am Cool Surg. 1994; 179: 285-288PubMed Google Scholar Symptoms ascribed to gastric phytobezoars include epigastric pain, early satiety, weight loss, nausea, and vomiting. Trichobezoars are less common than phytobezoars but are more frequently seen in young people. In the classic review by DeBakey and Ochsner,4DeBakey M Ochsner A Bezoars and concret ions: a comprehensive review of the l iterature with analysis of 303 collected cases and a presentation of 8 additional cases.Surgery. 1939; 5: 132-160sGoogle Scholar 80% of trichobezoars were found in patients younger than 30 years of age. With the ingestion of hair, carpet, and clothing, fibers become trapped in the gastric mucosal folds and become enmeshed. Gastric acid denatures hair proteins and blackens the bezoar regardless of the intrinsic color,7Anderson JE Akmal M Klttur OS. Surgical complications of pica: report of a case of mtest inal obstruct ion and a review of the literature.Am Surg. 1991; 57: 663-667PubMed Google Scholar Factors associated with trichobezoar formation include mental retardation, female gender, an underlying behavioral disorder leading to pica, and the compulsive and excessive ingestion of food or nonfood substances.7Anderson JE Akmal M Klttur OS. Surgical complications of pica: report of a case of mtest inal obstruct ion and a review of the literature.Am Surg. 1991; 57: 663-667PubMed Google Scholar, 8Bhatia MS Sinchal PK Rastogi V Dhar NK, Nltam VR. Taneja SD. Clinical profile of tri chotillomania.Indian Med Assoc. 1991; 89: 137-139PubMed Google Scholar The increased incidence of pica in females during pregnancy, patients undergoing longterm dialysis, and patients with other conditions in which anemia is frequently present may support the hypothesis that anemia, usually iron deficiency, may predispose to the development of pica. Our patient suffers from trichotillomania, a type of pica that was first described in 1889 as an irresistible urge to pull one's hair,9Greenberg HR Samer CA Trichotillomania: symptom and syndrome.Arch Gen Psychiatty. 1965; 12: 482-489Crossref PubMed Scopus (100) Google Scholar and subsequent trichophagia, the oral ingestion of hair. The treatment of trichotillomania and trichophagia can be difficult. Options include various medications, particularly the serotonin selective reuptake inhibitors; the behavioral technique of habit reversal by using play therapy; and hypnosis.10Christenson GA Crow SJ The characterizatio n and treatmen t of trichotlilomania.J Clin PSy Chiatry. 1996; 57: 42-47PubMed Google Scholar The diagnosis of a gastric trichobezoar can be confirmed by radiography or endoscopy. Plain films of the abdomen may reveal amorphous, granular, calcified, or whirlpool-like configurations of solid and gaseous material within the stomach.11Wdllnglon WS Rose M Holcomb Jr, OW Complicat ions of trichobezoars: a 3O-year experience.South Med J. 1992; 85: 1020-1022Crossref PubMed Scopus (41) Google Scholar In some instances, the bezoar is so compact that a layer of air envelopes it and, in light of the long-term accumulation, calcification is often observed, as in our patient. Upper gastrointestinal studies with use of contrast medium confirm the presence of a bezoar and may outline a concomitant gastric ulcer. On ultrasonography, the echogenic arc of air between the bezoar and the gastric wall is pathognomonic and may be enhanced if fluid is administered concomitantly during the examination. Computed tomography vividly demonstrates trichobezoars as free-floating filling defects within the stomach, especially in the presence of orally administered contrast medium. Therapy for any bezoar necessitates removal and prevention of recurrence. Small bezoars may be amenable to nasogastric lavage or suction, a clear liquid diet, and the use of prokinetic agents. Bezoars may be fragmented mechanically or through the use of digestive enzymes.12Dann DS Rubin S Psman H Deouranslnch M. Bauernfeind A, Berenborn M. The successful medical management of a phytobezoar.Aroh Intern Med. 1959; 103: 598-601Crossref Scopus (36) Google Scholar Fragmentation by enzymatic therapy with use of chymopapain, meat tenderizers, cellulase, or acetylcysteine has not been convincingly efficacious. Endoscopic retrieval and fragmentation are frequently used for proximal bezoars whose size and density are not prohibitive; however, the procedure can be technically challenging, and fragments may migrate distally and cause small bowel obstruction.13Dletlrlch NA Qiiu FC Postga strectomy phytobezoar-endoscopic diagnosis and treatment.Arch Surg. 1985; 120: 432-435Crossref PubMed Scopus (48) Google Scholar Novel therapies reporting successful removal include extracorporeal shock wave lithotripsy,14Benes J Chmel J Jodi J Stuka C Nevoral J Treatment of a gastric bezoar by extraccrpcrear shock wave lithotri ps y.Endoscopy. 1991; 23: 346-348Crossref PubMed Scopus (37) Google Scholar endoscopic removal with a gallstone lithotriptor,15Lubke HJ Winkelmann RS Berges W Mecklenbeck W Wlenbeck M Gastric phytobezo ar: endoscopic removal using the galls tone lithotripter.Z Gastroenterof. 1988; 26: 393-396PubMed Google Scholar and removal by a modified percutaneous approach in which laparoscopy is used.16Fll Ipl CJ Perdlk Q Hinder RA DeMeester TR Fltztlbbonll Jr, RJ Peters J. An intraluminal surgical approach to the management of gastric bezoars.Surg Endosc. 1995; 9: 831-833PubMed Google Scholar Of interest, a recently described technique from China incorporates a laser miniexplosive technique through an endoscope; in 100 patients, the cure rate was 100%.17Huang Ye Uu QS Quo ZH The use of laser ignited mini-explosive technique in treating 100 cases of gastric bezoars.Chung Hua Nei Ko Tsa Chih. 1994; 33: 172-174Google Scholar In 30 patients, however, multiple separate treatments were needed for complete eradication of the bezoar. Gastroscopy is particularly helpful in the setting of intraoperative gastric evaluation in which scarring from a previous gastric operation poses additional risk to the patient. Laparotomy is reserved for bezoars that have perforated (7%), have caused hemorrhage (10%), or are too large or obstructive to be managed less invasively.2Slen BJ Hunt RH Aezoers.in: Sleisinger MH Fofdtran JS Gastroint est inal Disease; Pathophysiology/ Diagnosis / Management. 5th ed. Saunders, Philadelphia1993: 758-763Google Scholar In our patient, endoscopic interpretation of the bezoar was that it was finn, calcified, intertwined, and of sufficient size that fragmentation was impossible. Gastric trichobezoars can be easily extracted through a small gastrotomy; the duodenum and jejunum should be palpated carefully for hair balls that may have broken off from the primary mass. In the presence of an intestinal bezoar discovered at laparotomy, the prevalence of a concurrent gastric bezoar is 20%. After trichobezoar removal, prognosis is good if psychiatric therapy to control habitual trichophagia is successful. In patients who have undergone gastrectomy, however, the recurrence rate of phytobezoars is 13.5% despite preventive measures.5Wang PY Skarsgald ED Baker RJ Carpet bezoar obstruction of the small intes tine.J Pedlatr Surg. 1996; 31: 1691-1693Abstract Full Text PDF PubMed Scopus (24) Google Scholar Pica is another condition that necessitates psychiatric evaluation to prevent recurrence. Although risk factors for pica (female gender, childhood, mental retardation, and African-American and Aboriginal race) are known, this behavior is not usually identified until a bezoar has been diagnosed. Thus, a bezoar should be considered in the differential diagnosis in a child with symptoms of gastrointestinal obstruction and a painless upper abdominal mass.