Gastric trichobezoar causing pain and intestinal pseudo-obstruction

M. Chevallay, M. Peter, B. Peiry, B. Egger

Objective

Bezoars are masses formed by the concretion of incompletely digested substances from different origins such as plants, drugs or hair. The latter is called trichobezoar. The gastric acid can’t digest the hair fibers and they get stuck in the mucosal folds and may cause intermitted pseudobstruction. It is almost exclusively seen in young females, 90% are younger than 20 years. The incidence of formation of a trichobezoar in patients suffering from trichophagia can be as high as 37% and are frequently associated with psychiatric disorders.

Methods

We present the case of an 11-year old girl addressed by his pediatrician with a two weeks history of epigastric pain, worse after eating and eased after vomiting. Her parents noticed a weight loss of 3kg in these two weeks and the absence of a stool passage for a couple of days. The girl presented a history of trichotillomania and trichophagia lasting at presentation 6 months with the development of a subtly alopecia. Abdominal ultrasound confirmed a 6 cm mass in the stomach with a complete loss of posterior echoes. Following that gastroscopy was conducted, which confirmed the diagnosis of a trichobezoar in the stomach. Unfortunately, the extraction of the bezoar by the endoscopic but also by a coordinated laparoscopic and endoscopic approach failed. Finally, a mini-laparotomy with gastrotomy was successful with extraction of a 11 x 6 cm mass formed by thousands of partially digested hairs. The postoperative follow-up was completely uneventful with a well-tolerated re-alimentation. The girl was discharged home 6 days after the intervention in good general condition.

Conclusion

The presence of a gastric Trichobezoar is a rare condition that may be a diagnostic challenge. Often, diagnosis is primarily based on the clinical history. In young females with abdominal pain and pseudo-obstruction gastric trichobezoar should be part of the differential diagnosis. Conventional laparotomy is still the treatment of choice to remove large bezoars. However, psychiatric consultations are necessary to prevent relapses.