Abstract
Bezoars are foreign bodies impacted in the digestive tract resulting of their ingestion and accumulation, involving mainly the stomach. The most common types are phytobezoars, contaning vegetables, fiber and seed and the trichobezoar, made of hair. The present case is the description of a 25-year-old female with nonspecific dyspeptic symptoms associated to intestinal habit change. The diagnosis was suggested by Computerized Tomography in association with clinical history - initially omitted by the pacient - of trichophagia for 10 years. Treatment consisted of Anterior Gastrotomy and remotion of the bezoar.
Foreign body; Trichophagia; Gastric Trichobezoar
CASE REPORT
IM.D., Surgeon at The Pedro Sanches Hospital - Poços de Caldas, Minas Gerais, Brazil
IIM. D., Neurologist
IIIM. D., Caridologist
IVIntern, Cardiology, Beneficiência Portuguesa Hospital of São Paulo - São Paulo - Brazil
VResident, Radiology, Itajubá Medical School, Minas Gerais, Brazil
Correspondence address
ABSTRACT
Bezoars are foreign bodies impacted in the digestive tract resulting of their ingestion and accumulation, involving mainly the stomach. The most common types are phytobezoars, contaning vegetables, fiber and seed and the trichobezoar, made of hair. The present case is the description of a 25-year-old female with nonspecific dyspeptic symptoms associated to intestinal habit change. The diagnosis was suggested by Computerized Tomography in association with clinical history - initially omitted by the pacient - of trichophagia for 10 years. Treatment consisted of Anterior Gastrotomy and remotion of the bezoar.
Key word: Bezoars. Foreign body. Digestive system.
INTRODUCTION
Bezoars are impacted foreign bodies in the digestive tract, resulting from their ingestion and accumulation, primarily affecting the stomack1.
In females 90% are trichobezoars, usually resulting from trichotillomania2,3. Moreover, they may cause various gastrointestinal disorders and should be considered as differentials to other syndromes, despite being relatively rare4. We describe a case of gastric trichobezoar.
CASE REPORT
SSM, 25 years old, female, referred to our institution due to a palpable abdominal mass, and the presumptive diagnosis of splenomegaly. The patient reported a history of intestinal colics, flatulence and evacuation of watery and dark stools several time a day, alternating with episodes of constipation, for about four months. She evolved with progressive, constrictive, moderate epigastric pain, which improved with the use of hyoscine. She also referred trichophagy started ten years earlier, eating hairs "compulsively and unconsciously", as well as anxiety and binge eating.
On physical examination the patient presented with overweight, traumatic alopecia in the occipital region and, on abdominal palpation, a five-fingers-distant to the left costal margin, relatively fixed, indurated, painless to palpation, with imprecise limits, epigastric mass.
Hematological and biochemical examinations were normal. Contrast computerized tomography (CT) of the upper abdomen revealed a hypodense, heterogeneous image in the gastric region; liver, spleen and pancreas had normal contours and attenuation coefficients; absence of free fluid in the abdominal cavity (Figure 1).
Considering the hypothesis of trichobezoar, the patient underwent anterior gastrotomy. A voluminous, stomach-shaped trichobezoar with 1,010 grams and 25 cm in length (Figure 2) was extracted. No mucosal injury was found on endogastric inspection. The patient had an uneventful recovery and was discharged on the fourth postoperative day with referral to the Psychiatry Department. She returned three months after surgery with improvement of intestinal symptoms and weight gain of 5 kg.
DISCUSSION
Although trichobezoar is generally associated with psychopathy, from chronic anxiety disorders to mental retardation, psychological disorders are not always evident. However, the presence of alopecia, halitosis, trichophagy and psychiatric disorders are present in 9% of cases.
Signs and symptoms are vague and insidious, and may even be asymptomatic. There are often: epigastric pain (70.2%), epigastric mass (70%), nausea and vomiting (64%), hematemesis (61%), weight loss (38%), diarrhea or constipation (32%)5. The presence of symptoms depends on the elasticity of the stomach, the size of the bezoar and the presence or not of mechanical and/or traumatic complications.
Imaging tests are valuable for the diagnosis. A plain abdominal radiograph has low specificity, because it shows only a heterogeneous epigastric mass. The contrast examination of the upper digestive tract, indicated for the differentiation of abdominal masses, is more valuable and specific, showing an intralumial, mobile, heterogeneous and aerated gastric mass4. Endoscopy is the examination of higher specificity and sensitivity, as it is able to directly visualize the mass and to establish the nature of the bezoar, though unable to anatomically define its extension4. CT is the most accurate imaging test to demonstrate bezoars, showing them as heterogeneous aerated masses with concentric peripheral contrast enhancement2.
Conservative methods for treatment of trichobezoar are not always possible (endoscopic removal and use of enzyme solutions) because they offer parallel risks of gastric perforation and intestinal obstruction4,1. Therefore, surgical treatment is most effective and thus dominant, leading to direct removal of the foreign body mainly through longitudinal anterior gastrotomy4. Due to the possibility of an association between psychiatric disorders and trichobezoar, monitoring by a neuropsychiatry service is necessary for all patients in order to avoid relapse or replacement of trichotillomania by other compulsive disorders4.
REFERENCES
- 1. Spadella CT, Saad-Hossne R, Saad LHC. Tricobezoar gástrico: relato de caso e revisão de literatura. Acta Cir Bras. 1998;13(2):154-7.
- 2. Castro LP, Coelho LGV. Divertículos, vólvulos, dilatação gástrica aguda, corpos estranhos (bezoares), infecções crônicas e outras doenças raras. In: Bicalho AS editor. Gastroenterologia. 1Ş ed. Rio de Janeiro: Medsi; 2004. p. 524-5.
- 3. Miranda CHD, Coelho LGV. Divertículos, vólvulos, dilatação aguda, corpos estranhos (bezoares), rotura gástrica e Crohn. In: Dani R, editor. Gastroenterologia essencial. 2Ş ed. Rio de Janeiro: Guanabara Koogan; 2001. p. 185-6.
- 4. Jesus LE, Novelli RJM. Tricobezoares. Rev Col Bras Cir. 2005; 32(3):157-9.
- 5. De Bakey M, Ochsner A. Bezoars and concretions: a comprehensive review of the literature with an analysis of 303 collected cases and apresentation of 8 aditional cases. Surgery. 1939;5(1):132-60.
Gastric trichobezoar - case report
Publication Dates
-
Publication in this collection
17 Dec 2010 -
Date of issue
Oct 2010
History
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Accepted
20 Oct 2006 -
Received
25 Aug 2006
