JURNALUL PEDIATRULUI – Year XI, Vol. XI, Nr.

43-44, july-december 2008

TRICHOBEZOAR WITH LARGE BOWEL

OBSTRUCTION IN CHILDREN – CASE REPORT

ES Boia1, Camelia Popescu2, Maria Trailescu1, A Pavel2

¹University of Medicine and Pharmacy “Victor Babes” Timisoara
²Clinical Emergency Hospital for Children ”Louis Turcanu” Timisoara - Pediatric Surgery and
Orthopedics Department

Abstract acoustic interfaces created by trapped air and food

A trichobezoar is a mass of cumulated hair within the limits the ultrasonography of the trichobezoars
[3],[4],[5],[6]
gastrointestinal tract. Stomach is the common site of . Both, the contrast radiography and the
occurrence. Intestinal obstruction due to trichobezoar endoscopy of the upper GI tract are the diagnostic
is extremely rare. In this report, we describe one case procedures of choice for establishing the
of an atypical localization of a trichobezoar in an 11- diagnosis[3],[6]. The upper GI contrast radiography
year-old girl, who presented with large bowel confirms the existence of the trichobezoar and might
obstruction. We performed an exploratory laparotomy detect other complications such as gastric ulcers. In
and we diagnosed a movable intraluminal tumor of the addition, the upper endoscopy is definitively the
left angle of transverse colon. Treatment consists of diagnostic support for trichobezoar; it might be used
milking the contents to the rectum. for endoscopic retrieval of proximal small
Key words: trichobezoar, children, bowel obstruction. trichobezoars[3]. The computed tomography (CT-scan)
is the most useful diagnostic tool in patients with
Introduction bezoars because it reveals the localization of the bowel
For centuries, different types of bezoars obstruction; it shows also a well-defined intraluminal
(accumulations of foreign matter) have been known to mass of the bezoar in the transitional zone of the
occur in the stomach and intestines of animals and obstruction. A mottled gas pattern in the mass is
humans. Trichobezoars are classically described as reported characterizing the bezoar, and it is supposed
consisting mostly of hair, and are often noted in to be air bubbles retained within the bezoar[6],[7].
psychologically impaired children who also have Recently, researchers have recommended magnetic
trichotillomania (a compulsion to pull out one's hair)[1]. resonance imaging (MRI) for the evaluation of small-
Rapunzel's syndrome, due to compulsive hair-chewing, bowel disease. Fast imaging techniques coupled with
results in the formation of a long-tailed trichobezoar, a advantages of breath holding improved MRI
documented variant of trichobezoars. [1] visualization of bezoars. Therefore, MRI is found to be
Patients with bezoars often present with abdominal better support for determining both the site and the
pain, anorexia or vomiting, anemia, and malnutrition cause of small-bowel obstructions. MRI shows the
of different degrees. Signs and symptoms of bowel bezoar as a mass in the small bowel containing mottled
obstruction or perforation may occur. Occasionally the and confluent low signal intensities on both T1- and
patient is entire asymptomatic[2]. T2-weighted MR images[7].
Various imaging modalities have been recommended
for detection of bezoars[3],[4].The imaging findings are Treatment
helpful in diagnosing trichobezoar. The conventional Once the diagnosis is established, trichobezoar
radiography shows a masse of opaque soft tissue in a removal should be undertaken to avoid the
swollen stomach[3],[4],[5] and can reveal bowel complication of obstruction, hemorrhage, ulceration,
obstruction with dilated small bowel loops with fluid perforation and peritonitis and to reestablish proper
and air-filled loops proximal to the site of obstruction nutrition[2].
and distal collapsed small bowel. A calcified rim may The upper endoscopy of GI tract might be used for
delineate the edge of the bezoar[3],[5]. The endoscopic retrieval of proximal small trichobezoars.
ultrasonography shows a typical curvilinear Definitive treatment consists of exploratory
trichobezoar with bright echogenic band, this does not laparotomy with trichobezoar removal commonly done
allow transmitting the ultrasound waves which by gastrotomy and/or enterotomy or milking of
generate a shadow over the left upper quadrant. The contents to the rectum. If complicated, the
high echogenicity of hair and the presence of multiple trichobezoars can be treated by subtotal gastrectomy

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and/or intestinal resections. If trichobezoar is into the abnormality. A positive diagnosis of intestinal
colon, then colonoscopic evacuation can be performed. obstruction was established based on the previous
Medical treatment is usually inadequate. examinations.

Case report Treatment:

We present the case of a girl R.A., 11 years’old, Preoperative care consisted in gastric decompression
coming from urban area, transferred in our clinic with using nose-gastric tube, parentheral nutrition,
the diagnosis: subocclusive syndrome. antibiotics (piperacilin tazobactam) and infusion with
electrolytes.
History and clinical findings: Surgery –consisted of the following steps:
She had a history of two weeks of colicky abdominal *median abdominal incision;
pain, nausea, vomiting, decreased oral intake, changes *abdominal cavity exploration- revealed normal
in bowel movements. At admission in the hospital she stomach, duodenum and ileum, inflammatory
presented altered general state, pouched eyes, pale adhesions at the first jejune loops with a small blocked
teguments, bilious vomiting, and constipation. The perforation at 5-7cm from duodeno-jejunal junction.
distended abdomen was diffusely sensitive to The thorough exploration of the large bowel revealed
palpation, with no sign of peritoneal irritation. one intraluminal movable tumor of the left angle of
Abdominal auscultation revealed static intestinal transverse colon which could be milking to the rectum;
sounds (borborism). Digital rectal examination this intraluminal tumor retained in this site compressed
revealed empty rectal ampulla, without presence of any the first jejunal loop, affecting the vascular supply with
pathological material on the hand gloves. Next day she secondary ischaemic perforation;
presented signs of peritoneal irritation in the left * lysis of adhesions, jejunoraphy in double layer;
abdomen. *lavage of the abdominal cavity using NaCl 0.9%;
*double drainage of the abdominal cavity, suture of the
Paraclinical: abdominal wall;
The blood count showed a marked leucocytosis, high *anal dilatation and pull-out the tumor which was a
number of thrombocytes, high acute phase reactants, trichobezoar.
increased level of urea, and signs of acute dehydration The postoperative care consisted of antibiotics
with hyponatremia. (piperacilin tazobactam, solution of parentheral
Abdominal X-ray showed multiple air-fluid levels nutrition (glucosis, aminoacids), electrolytes, antalgic
without presence of air under the diaphragm, while the drugs.
ultrasound examination was negative for any

Fig .1. The trichobezoar.

Discussions fibers[3],[4],[8],[10].The bezoar is mostly caused by the

Bezoars are foreign bodies in the lumen of the presence of indigestible substance in the lumen. Some
digestive tract. The lumen size increases in time by the substances encourage stickiness and concrete
accumulation of ingested nonabsorbable food or formations[6],[8],[11].Bezoar occurs mainly in female

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children, who chew and swallow their hair occur with GI bleeding (6%) and intestinal obstruction,
(trichobezoar), vegetable fibers (phytobezoar), or perforation (10%)[3],[11].The most common sites of
persimmon fibers (diospyrobezoar), or semi-liquid obstruction are the gastric outlet, or duodenum.
masse of drugs (pharmacobezoar)[3],[4],[11]. Obstructions of distal parts of the small bowel or the
Trichobezoar (hairball) is a complication of large bowel are extremely rare. [3]The examination of
trichotillomania. It consists of recurrent hair pulling, the hair content in stool would establish the diagnosis,
and subsequent trichophagia or mouthing of the hair but usually it is not done[3],[4].It is mandatory to
[5],[8],[9],[10]
. perform a thorough exploration of all the small
During the time, these substances are retained by intestine and the stomach searching for retained
mucus and become enmeshed; this yields a mass bezoars.
having the shape of the stomach localization where
they are usually found[8],[11].These substances attend Conclusions
large size due to the chronicity and delayed Trichobezoar is a rare clinical entity. Stomach is
investigation of the affection. The age of occurrence of the common site of occurrence. In this case the large
bezoars has been reported to range between 1 and 56 bowel obstruction occurred because of the trichobezoar
years old[3],[5],[8].Although about 1 of 2000 children itself which have migrated from stomach and have
suffer from trichotillomania, trichophagia is rarely stopped in the splenic angle of transvers colon. The
seen, and a bezoar does not occur in all children with retained trichobezoar in this site compressed the first
trichophagia [3],[10]. Reduced intestinal motility is the jejunal loop, affecting the vascular supply with
most quoted factor in the intestinal bezoar formation. secondary ischaemic perforation. This case was
Bezoars mostly originate at the level of the diagnosed in a complicated stage(mecano-inflamatory
stomach[3],[5],[8],[11], it is probably related to high fat diet bowel obstruction) so the pacient wiil have high risk to
causing unspecific symptoms like epigastric pain, develop early and tardive postoperative complication
dyspepsia, and postprandial fullness. The stomach is (peritoneal abceses, intestinal adhesions).After surgery
not able to exteriorize hair and other substance out of the pacient was treated in collaboration with a
the lumen because the friction surface is not sufficient pshyatryc doctor, too.
for propulsion by peristalsis. The bezoars might also

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Correspondence to:
Eugen Boia,
Gospodarilor Street, No. 42,
Timisoara 300778,
Romania,
E-mail: [email protected]

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