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The Stomach Full of Hair-Trichobezoar |
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Raghav Yelamanchi, Gayathri Dharma Teja Manda, Gautam Kumar Chukka, Manoj Dokania 1. Senior Resident, Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India. 2. Resident, Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India. 3. Resident, Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India. 4. Consultant, Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India. |
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Correspondence Address : Raghav Yelamanchi, Ward 17, Old Building Dr Ram Manohar Lohia Hospital, New Delhi, India. E-mail: raghavyelamanchi@gmail.com |
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| ABSTRACT |  | ||||||||||||||||||||||||||
: Trichobezoars are rare masses of hair resulting from hair plucking (trichotillomania) and hair eating (trichophagia). Few of the hair may also be carried by peristalsis into the duodenum. This condition is known as Rapunzel syndrome. Complications include gastric perforation, small bowel obstruction and pancreatitis. Here the authors present a case of 20-year old female patient who presented with complaints of abdominal pain, early satiety and non-bilious vomiting. On examination, there was a swelling of size 10×5 cm predominantly in the epigastric and umbilical regions. Contrast Enhanced Computed Tomography (CECT) of the abdomen revealed a grossly dilated stomach with a heterogeneous mass in the lumen obstructing the pylorus. Upper gastrointestinal endoscopy confirmed the diagnosis of trichobezoar. Trichobezoar was removed by laparotomy and the patient had an uneventful recovery. Treatment is mainly laparotomy and minimally invasive methods can be used for small lesions with limited success rate. Psychiatric consultation is a must in all cases. | |||||||||||||||||||||||||||
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| Keywords : Trichotillomania, Trichophagy, Rapunzel syndrome, Gastric outlet obstruction, Laparotomy | |||||||||||||||||||||||||||
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DOI and Others :
DOI: 10.7860/IJARS/2022/52792.2799
Date of Submission: Oct 08, 2021 Date of Peer Review: Jan 12, 2022 Date of Acceptance: Feb 23, 2022 Date of Publishing: Jul 01, 2022 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. Yes PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Oct 11, 2021 • Manual Googlin |
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| Case Report |
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A 20-year old female patient had presented to the Surgical Outpatient Department (OPD) with complaints of abdominal pain, early satiety and non bilious vomiting a few hours after taking food for two months. Abdominal pain was localised in the epigastric region and was colicky type. Abdominal pain increased on taking food and relieved on vomiting. Vomiting was non projectile and non bilious and occurred few hours after taking food and consisted of undigested food particles. There was early satiety which has progressed gradually. There was history of significant loss of weight. There was no history of any corrosive intake or other gastrointestinal symptoms. There was no significant past, personal or family history. On examination, there was a swelling of size 10×5 cm palpable predominantly in the epigastric and umbilical regions and firm in consistency. Swelling was moving with respiration and had limited mobility. Rest of the abdominal examination was normal. A provisional diagnosis of gastric outlet obstruction was made based on the clinical history and examination. Ultrasound of the abdomen revealed dilated stomach filled with heterogeneous contents. Contrast enhanced computed tomography of the abdomen revealed a grossly dilated stomach with a heterogeneous mass in the lumen obstructing the pylorus suggestive of a bezoar (Table/Fig 1)(a),(b). Upper gastrointestinal endoscopy showed a large trichobezoar causing gastric outlet obstruction. On further probing, there was no history of any psychiatric illness or hair eating. Complete blood picture, serum electrolytes, arterial blood gas analysis, renal function tests and liver function tests were carried out. Serum sodium was 125 Meq/L and serum potassium was 2.7 Meq/L. After preoperative correction of the electrolytes and optimisation, laparotomy was done. The stomach was opened in the anterior wall and the trichobezoar was removed (Table/Fig 2). There was no extension noted into the duodenum. Gastrotomy was closed with 3-0 polyglactin suture buttressed with 3-0 silk suture. Drain was placed and abdominal wall was closed in layers. The patient had an uneventful postoperative recovery and psychiatric consultation was done before discharge. At one year, follow-up patient gained weight and has no symptoms either of gastric outlet obstruction or any psychiatric illness. Even though in this case, there is no history suggestive of any psychiatric illness, it may be because of the false history given by the patient or her parents or history of trichotillomania in the early childhood which the patient may not remember and overlooked by her parents. | |||||||||||||||||||||||||||
| Discussion |
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Trichobezoars are rare masses of hair, clumped with food particles and debris. Most common etiologies include psychiatric illness resulting in hair plucking (trichotillomania) and hair eating (trichophagia) of self or dolls but patients may deny such history (1). Trichotillomania is common in females. Keratin protein is not digestible by human enzymes and hence accumulates in the stomach over years. They slowly grow in size with repeated consumption of hair and result in the formation of a large mass in the shape of the stomach. Few of the hair strands may also be carried by peristalsis into the duodenum and as far as distal small bowel. This condition is known as the Rapunzel syndrome, first described by Vaughan Jr ED et al named eponymously after a character in a fairytale with long hair (2).Examination of the scalp of the patient may show loss of patches of hair due to the habit of hair plucking. Most of these cases present with history of gastric outlet obstruction.Epigastric pain and lump were the most common symptoms followed by vomiting in the previous case reports (1),(2),(3),(4),(5). Many of these young adults also present some form of chronic malnutrition and anaemia which is attributed to decreased food intake. However, some rare presentations of trichobezoars have been reported previously in the literature. Parts of the hair may also be broken down and carried forward by peristalsis. These hair fragments may cause small bowel obstruction in the distal segments (3). Long-standing cases can erode the wall of the stomach and cause gastric perforation and may present with acute abdominal emergency (4). Rare complications such as pancreatitis have also been reported due to trichobezoar (5). Imaging findings are suggestive but not diagnostic of this condition. On ultrasound, the trichobezoar appears as a hyperechoic mass with posterior acoustic shadowing. Computed Tomography (CT) shows a heterodense intraluminal lesion. There may be foci of air trapped inside the mass. Usually, the bezoar is surrounded by a thin layer of fluid from the wall of the stomach. Upper gastrointestinal endoscopy is required for the confirmation of the diagnosis (6). Many methods have been tried for the treatment of trichobezoar. Non operative methods such as enzymatic digestion have largely been unsuccessful. Laparotomy is still the gold standard for removing trichobezoar especially when there is adhesion with the wall of the stomach and when Rapunzel syndrome is suspected. Minimally invasive surgery such as laparoscopic removal has been successful in some cases with the first reported case by Nirasawa Y et al (7). However, the conversion rate to open surgery is quite high. Psychiatric evaluation is a must in all patients, as all patients with trichobezoars were diagnosed with psychiatric illness at some point in their lives (1),(8),(9). Findings of few published case reports is described in (Table/Fig 3) (1),(3),(8),(10),(11),(12). | |||||||||||||||||||||||||||
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