Teaching Case

A 9-year-old female with multiple recent presentations to A&E with complaints of abdominal pain and vomiting, treated initially as gastroenteritis. She now presented with a 2-week history of vomiting, mostly bilious content, but with suspicion of hair being present on a few occasions, abdominal pain, reduced oral intake, constipation as well as intermittent mild fever.

On examination, she had generalised abdominal tenderness, worst in the epigastric region as well as mild abdominal distention.

On initial investigation, a plain abdominal radiograph showed dilated proximal jejunal loops with a maximum diameter of 4 cm, indicating a small bowel obstruction (Figure 1).

A CT abdomen and pelvis with contrast was then performed which showed a non-obstructive independent trichobezoar in the stomach measuring 3.8 cm as well as another two in the jejunum of varying sizes resulting in small bowel obstruction, with dilated proximal small bowel loops but non-dilated distal ileal loops and no pneumoperitoneum (Figures 2a, 2b and 2c).

A bezoar is an amalgamation of an indigestible substance that accumulates over time in the gastrointestinal tract. Trichobezoars are a rare form of bezoar, usually found in the stomach or small bowel, due to ingestion of hair over a period of time, also known as trichophagia [1]. They are usually found in young females with underlying psychiatric disorders [2].

In this case, the patient presented repeatedly over the course of two weeks with complaints of nausea, vomiting, reduced oral intake, epigastric pain and constipation. Some patients can also present with an epigastric mass [2] and halitosis though these were not noted in this presentation. On examination, there was epigastric and central abdominal tenderness with mild distention of the abdomen. Upon further evaluation, the parents mentioned a history of trichophagia.

Initially, a plain abdominal film was done, which showed dilated proximal small bowel loops indicative of a small bowel obstruction. For further evaluation and to identify the exact point of obstruction in order to plan surgical intervention, a contrast CT scan of the abdomen and pelvis was carried out. Although ultrasound is also a reliable method for diagnosing gastrointestinal bezoars, CT is more accurate and is much more sensitive in identifying multiple bezoars [3]. The scan confirmed the presence of trichobezoars, one in the stomach and two in the small bowel resulting in obstruction. The patient underwent laparotomy as well as small bowel resection and anastomosis; the bezoars were successfully removed.

Although a rare occurrence, trichobezoars and their possible complications should be kept in mind as differentials, especially in patients with a history of trichophagia. Early diagnosis and management can reduce risk of severe complications [4].

All patient data has been completely anonymised throughout the entire manuscript and related files.