Large gastric trichobezoar in a normal healthy woman: case report and review of pertinent literature.

Abstract: This report presents a unique case of a gastric trichobezoar in a relatively healthy, young female with no history of psychological or psychiatric disorders. Furthermore, unlike previously reported cases, this patient had no history of gastric surgery. The mode of presentation and the difficulties in diagnosis are discussed. The different modalities of treatment, both surgical and nonsurgical, are evaluated and discussed. The diagnosis of a trichobezoar in a healthy patient requires a high index of suspicion, as it can present with nonspecific symptomatology. It should be included in the differential diagnosis of nonspecific abdominal pain.

Key Words: bezoar, trichobezoar, gastric, female

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The word bezoar is derived from the Arabic "badzehr" or from the Persian "padzahr," and it means antidote. Today, the term bezoar refers to swallowed material (either food or foreign body) that fails to clear from the stomach and accumulates into masses of concretions. (1) However, even large foreign bodies are cleared from the stomach of normal individuals in 80 to 90% of patients. Therefore, bezoar formation usually implies altered gastric anatomy or physiology as well as continued ingestion of the offending substance. (2) The offending substance may be vegetable fibers (phytobezoars), animal fats, antacids, hair (trichobezoar), or pills (pharmacobezoar).

Gastric bezoars are most common after gastric surgery, but in patients who have not undergone surgery, gastric bezoars are almost always accompanied by an underlying psychiatric problem, such as trichotillomania (the irresistible urge to pull one's own hair). They rarely occur in patients with diabetes mellitus (altered gastric physiology), myotonic muscular dystrophy, and cimetidine therapy. (2)

Case Report

An 18-year-old female presented to her general practitioner with chronic indigestion-like epigastric pain. The pain was intermittent and radiated to the back. It was associated with a reduced appetite and weight loss and intermittent constipation. The pain was worse on an empty stomach and was relieved by eating.

She had presented to an accident and emergency department before this complaint, at which time a diagnosis of reflux esophagitis was made and cimetidine had provided some relief. However, the intermittent epigastric pain had returned.

Her medical history included pica as a 3-year-old, when she was reported to have eaten books, crayons, water paints, blue tack, and occasionally soil. She was described as a happy child despite an "unsatisfactory housing situation," and the pediatrician had suggested boredom and frustration as contributing factors to her condition.

On examination, her abdomen was nontender, with a palpable epigastric mass. Bowel sounds were normal. On the basis of this, she underwent an urgent gastroscopy that revealed a large trichobezoar within the stomach. A barium meal at that time showed an otherwise normal esophagus, stomach, and duodenum, with no sign of gastric outlet obstruction but with confirmation of a trichobezoar. She was started on a prokinetic therapy, cisapride, in the hopes that this would clear her gastric bezoar. She became pregnant in the interim period and was lost to follow-up. One year later, after a symptom-free and uncomplicated pregnancy, she presented with recurrent colicky abdominal pain keeping her awake at night. There was no association with food and she complained of a weight loss of 10 kg in 1 year. She was therefore referred to a surgeon for surgical intervention in view of her previous findings of trichobezoar. The procedure was performed electively after a repeat barium meal. The trichobezoar was removed en mass easily via a generous gastrotomy, as it was occupying the entire stomach (Figs. 1 and 2). She recovered well from the procedure without any complications and was symptom-free on discharge. She had three more children.

Discussion

Trichobezoars are most commonly found either in childhood or among teenage girls with psychological disorders, for example, mental retardation or behavioral disorder, such as trichotillomania or trichophagia. (3) In the classic review by Debakey and Oschner, (4) of 311 patients, 80% of trichobezoars were found in those younger than 30 years of age. Our patient had a history of pica in childhood but certainly had no psychological, emotional, or behavioral problems, either as a child or as a teenager.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Not much is known about the mechanism of bezoar formation in the nonoperated stomach, but Debakey and Oschner (4) proposed that trichobezoars develop from hair trapped within the gastric folds. This, however, does not explain why large hair balls remain in the stomach. (4) Even in postoperative patients, studies have shown no difference in the emptying of solids in patients with and without bezoars. (5) Some reports do suggest that delayed emptying in post-vagotomy patients may contribute to the formation of bezoars. (6) It has been proposed that impairment of the sieving and grinding mechanisms of the stomach, more than the emptying, might contribute to the formation of bezoars.

During trichobezoar formation, hair, carpet, and clothing gets trapped in the gastric mucosal folds and becomes enmeshed. Gastric acid denatures hair proteins and blackens the bezoars irrespective of the intrinsic color. (7)

There are no pathognomonic symptoms or signs of gastric bezoars.

The common complaints include abdominal pain, nausea, bloating, early satiety, and weight loss. Uncommonly, patients with trichobezoars vomit or pass fragments of hair in stools. (2) In the absence of bowel obstruction, almost all patients have a relatively benign presentation, as was the case in our patient. They can present with epigastric pain simulating a peptic ulcer or upper gastrointestinal bleeding from an associated gastric ulcer. Malabsorption, pancreatitis, protein-losing enteropathy, and dysphagia have been described but are rarely seen. (8,9) Clinical examination for diagnosis is generally unrewarding, and the differential diagnosis is broad, due to the nonspecific signs and symptoms of gastric bezoars.

Both ultrasonography and CT are reliable methods of diagnosing gastrointestinal bezoars. CT is more accurate and acquires quite a characteristic bezoar image. In addition, it is able to reveal the presence of additional gastrointestinal bezoars. (10) The definitive diagnosis of bezoars is established by endoscopy. Endoscopy of the duodenum is essential to rule out an extension of the tail of bezoars (Rapunzel syndrome). (11)

Therapy for gastric bezoars 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. (12) Most trichobezoars, however, require surgery for removal. The standard treatment is a gastrotomy and extraction of the bezoar, as was the case in our patient. (13) Novel therapies include extracorporeal shock wave lithotripsy, NdYaG laser, and endoscopic and laparoscopic removal. A new mini-explosive technique through an endoscope has claimed 100% success in China. (14,15) Recently, reports of successful laparoscopic removal of trichobezoars have been reported. (16) Enzymatic treatment has been described but is mainly for phytobezoars.

After trichobezoar removal, prognosis is good if psychiatric management to control habitual trichophagia is successful. (12) Treatment includes selective serotonin uptake inhibitors, play therapy (for children) and hypnosis. (17)

Recurrence is known and can occur if the underlying psychological condition is not treated. (13,18)

Pharmacobezoar is an evolving entity. In contrast to nonmedication bezoars, pharmacobezoars may produce additional symptoms related to the active ingredient (19) and can be lifethreatening.

Conclusion

Bezoars require a high index of suspicion for diagnosis, and it should be considered in young female patients with possible psychiatric problems or with long-standing abdominal symptoms. Our case was unique because of the absence of any psychiatric history. Furthermore, our patient at 5-year follow-up is symptom free and had no further recurrence of trichobezoar.

References

1. Williams RS. The fascinating history of bezoars. Med J Aust 1986;145:613-614.

2. Lee J. Bezoars and foreign bodies of the stomach. Gastrointest Endosc Clin N Am 1996;6:605-619.

3. Sharma NL, Sharma RC, Mahajan VK, Sharma RC, Chauhan D, Sharma AK. Trichotillomania and trichophagia leading to trichobezoar. J Dermatol 2000;27:24-26.

4. Debakey M, Oschner A. Bezoars and concretions: Comprehensive review of literature with analysis of 303 collected cases and presentations of 8 additional cases. Surgery 1939;5:132-160.

5. Calabuig R, Navarro S, Carrio I, Artigas V, Mones J, Puig LaCalle J. Gastric emptying and bezoars. Am J Surg 1989;157:287-290.

6. Brady PG. Gastric phytobezoars consequent to delayed gastric emptying. Gastrointest Endosc 1978;24:159-161.

7. Anderson JE, Akmal M, Kittur DS. Surgical complications of pica: Report of a case of intestinal obstruction and a review of literature. Am Surg 1991;57:663-667.

8. Hossenbocus A, Colin-Jones DG. Trichobezoar, gastric polyposis, protein losing gastroenteropathy and steatorrhea. Gut 1973;14:730-732.

9. Shawis RN, Doig CM. Gastric Trichobezoar associated with transient pancreatitis. Arch Dis Child 1984;59:994-995.

10. Ripolles T, Garcia-Aguayo J, Martinez MJ, Gil P. Gastrointestinal bezoars: Sonographic and CT characteristics. AJR Am J Roentgenol 2001;177:65-69.

11. Vaughan ED Jr, Sawyers, JL, Scott HW Jr. The Rapunzel Syndrome: An unusual complication of intestinal bezoar. Surgery 1968;63:339-343.

12. Phillips MR, Zaheer S, Drugas GT. Gastric Trichobezoar: Case report and literature review. Mayo Clin Proc 1998;73:653-656.

13. Robles R, Parrilla P, Escamilla C, Lujan JA, Torralba JA, Liron R, Moreno A. Gastrointestinal Bezoars. Br J Surg 1994;81:1000-1001.

14. Huang YC, Liu QS, Guo ZH. The use of laser ignited mini-explosive technique in treating 100 cases of gastric bezoars. Zhonghua Nei Ke Za Zhi 1994;33:172-174.

15. Benes J, Chmel J, Jodl J, Stuka C, Nevoral J. Treatment of a gastric bezoar by extracorporeal shock wave lithotripsy. Endosc 1991;23:346-348.

16. Yao CC, Wong HH, Chen CC, Wang CC, Yang CC, Lin CS. Laparoscopic removal of large gastric phytobezoars. Surg Laparosc Endosc Percutan Tech 2000;10:243-245.

17. Christenson GA, Crow SJ. The characterization and treatment of trichotillomania. J Clin Psychiatry 1996;57(Suppl 8):42-49.

18. Ratnagiri R, Smile SR, Sistla SC. Recurrent gastric trichobezoar. Indian J Gastroenterol 2002;21:229-230.

19. Stack PE, Thomas E. Pharmacobezoar: an evolving new entity. Dig Dis 1995;13:356-364.

Education is a progressive discovery of our own ignorance.
--Will Durant

Rachel Coulter, MBBS, Martin Thomas Antony, MBBS, FRCS, Prajesh Bhuta, MBBS, FRCS, and Muhammed Ashraf Memon, FRCS

From the Department of Surgery, Whiston Hospital, Warrington Road, Prescot, Merseyside, United Kingdom.

Reprint requests to M. A. Memon, FRCS, Astley House, Whitehall Road, Darwen, Lancashire BB3 2LH, UK. E-mail: [e-mail]

Accepted June 30, 2005.

RELATED ARTICLE: Key Points

* Gastric trichobezoar are usually found in patients with a history of psychological/psychiatric disorders.

* A large proportion of these gastric trichobezoars are found in patients with previous gastric surgery.

* Clinical manifestations vary from no symptoms to acute abdominal syndrome.

* Treatment can be conservative, medical, or surgical.

* Recurrence is possible because of the patient's characteristics or abnormal gastric anatomy.