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INTRODUCTION
The word 'Bezoar', comes either from the Arabic word "bedzehr", or the Persian word "padzher", meaning protecting against a poison or antidote. In ancient times, the solid mass occasionally found in the stomach of a goat or an antelope was thought to have magical healing powers and even rejuvenating properties [1]. In modern medicine, the concretion found in the stomach and intestine of humans and referred by the term bezoar, is associated not with such positive effects, but with significant morbidity and even mortality.
Most bezoars are the result of ingestion of indigestible organic matter such as hair (Trichobezoar) or vegetable and fruit matter (Phytobezoar), or a combination of both (Trichophytobezoars) [2]. Persimmon seed and other fruit products are frequently reported factors in their formation [3].
Trichobezoars are seen almost exclusively in female children, 6-10 years old, with bizarre appetite and emotional disturbances [4]. Bezoars produce multiple clinical manifestations. These depend on the location of bezoars. Gastric bezoars may cause dyspepsia, weakness and weight loss. These may be associated with gastric outlet obstruction, ulceration and perforation. Hair strand become retained in the folds of the gastric mucosa because the friction surface is insufficient for propulsion by peristalsis [5]. Distal extension of the bezoar can lead to obstructive jaundice, acute pancreatitis, protein losing enteropathy, steatorrhea, mechanical small bowel obstruction alone or with perforation.
Diagnosis can be established either by the barium contrast studies or by CT scan. Ultrasound might suggest the diagnosis, but sonographic features are definitely not pathognomonicBezoars can be managed by various means, depending on their underlying nature and location. Currently non-surgical techniques of management of gastrointestinal bezoars may include: dissolution, suction, lavage, mechanical endoscopic fragmentation using pulsating jet of water, and fragmentation using extraocorporeal shock wave lithotripsy [3]. If these methods fail, gastrotomy and manual removal is the only means of relieving the patient. Large bezoars will generally need surgery for removal. Besides dissolution or removal, psychiatric follow-up may be necessary to reduce the frequency of recurrence.
CASE HISTORY
A nine years old girl reported to the out- patients clinic with a history of intermittent epigastric pain and vomiting of five months duration. The patient had a sensation of fullness at the epigastrium with vague distress, nausea and anorexia. According to the parents the child enjoyed good health prior to this and her past medical history was uneventful. She was given some symptomatic treatment. The child did not get relief of her symptoms and reported back after one week. She was referred to surgical out - patients clinic.
Physical examination revealed a skinny girl with pale conjunctivae. Systemic examination including abdominal examination did not reveal any significant abnormality. There was no abdominal guarding, rigidity or tenderness. No apparent alopecia was noted in the patient.
Laboratory workup of the patient exhibited a mild hypochromic microcytic anemia (Haemoglobin 9.0 gm/ dl). All other investigations were within normal limits. A plain chest film was also normal.
She was referred to radiology department with a request for contrast studies of upper gastrointestinal tract. The patient was called next morning after overnight fasting. The study was carried out on Heliophos 4E, 300mA, X-ray machine under fluoroscopy.
Barium contrast studies of upper gastrointestinal tract revealed a large, mottled, intraluminal space occupying lesion with a honeycomb appearance in the fundus of stomach (Fig-1). Delayed films, taken three hours later, showed multiple, small, intraluminal filling defects in the duodenum (Fig-2). A radiological impression of gastrointestinal bezoar was made. When questioned, she admitted to a history of tricophagia for as long as she could recall. Further questioning of the girl revealed epigastric complaints for many months and she confirmed "eating hair when nervous". The family and social history uncovered her mother, a psychiatric patient and the father, an addict. There were frequent domestic fights, claiming the girl responsible for the household crisis. Furthermore the mother menaced her by telling her" she was sick of her". Psychiatric evaluation revealed a depressed, frightened, neglected child who relieved her anxiety by eating her hair (trichophagia).
Keeping in view large size of the bezoar and its extension to the duodenum, surgical removal was considered. She was taken to the operating room. Under general anaesthesia an anterior longitudinal gastrotomy incision was made. On laparotomy, a large hair ball extending from stomach into the duodenum and proximal jejunum was removed without difficulty. The mass had the shape of stomach and proximal part of the duodenum. It had brilliant surface and putrefactive odour. The gastric mucosa was normal and not adhered to the mass.
Oral feeding was resumed on the sixth postoperative day. The child was discharged after adequate psychiatric therapy. Psychiatric therapy of the parents was also done.
DISSCUSSION
Diagnosis of trichobezoars rests on clinical evidence of long standing history of trichophagy, and conventional radiological investigations such as plain abdominal films, contrast upper gastrointestinal series, ultrasonography, or computerized abdominal tomography. The majority of bezoars are preoperatively diagnosed or confirmed on upper GI barium study. However Stelzner is believed to have been the first to record a correct preoperative diagnosis on the basis of physical examination in 1896 [6].
Plain film of abdomen may show a mass invading the gastric bubble. The upper part of a large bezoar may be visible as a mass with a convex upper border projecting into the gastric air bubble. An erect abdominal radiograph and a supine radiograph may also show a prominent gastric outline with an intragastric mottled mass, outlined by gas in the distended stomach mimicking a food-filled stomach.
With a small amount of barium the hair ball gets coated and becomes visible. Filling up the stomach with barium demonstrates a free mobile intraluminal filling defect (Fig-1), or mass of variable size in barium field (with less penetration of the barium into the mass in case of phytobezoars as compared to trichobezoars). Intragastric mass has a honeycomb like surface, around which the contrast medium flow may readily be observed. The mass/filling defect may show extension into the duodenum (Fig-2). The positive density of the mass due to residual contrast medium may be seen on delayed films. The study should be continued till the contrast reaches the ileo-cecal region to look for any extension, dislodging, or synchronism of the gastric bezoar.
Ultrasonography may demonstrate a superficially located broad band of high amplitude echoes along the anterior wall of the mass with sharp, clean posterior shadowing. This characteristic appearance persists irrespective of the transducer angulation, alteration of the patient's position and the administration of clear water. This can be attributed to multiple tiny interfaces between the smooth, compressed, compact mass and the entrapped air and food debris. Heavily calcified mass such as teratoma, neuroblastoma or impacted mass of feces may produce a similar ultrasound image. Plain abdominal radiographs and barium meal study are helpful in excluding these entities, as well as confirming the diagnosis of gastric trichobezoar [6].
Plain abdominal computed tomography usually shows a mobile intragastric mass consisting of "compressed concentric rings", with a mixed density pattern due to the presence of entrapped air and food debris [7].
Rapunzel syndrome is ascribed to those gastric bezoars that have a tail-like extension of twisted hair reaching the ileocecal valve. Obstruction of gastric outlet or intestinal obstruction is caused by either small broken off pieces or through long string like extensions of the main mass going in certain cases up to ileocecal valve or even transverse colon [8].
Possibility of trichobezoars should be considered in patients with some underlying emotional stress leading to trichophagy, Although trichophagia is not frequently related to full blown neuro-psychiatric disturbance but it is said that the trait represents a personality disorder analogous to the finger nail biting. Besides dissolution or removal, treatment should focus on prevention of recurrence, since elimination of the mass will not alter the conditions contributing to bezoar formation. Psychiatric follow-up may be necessary to reduce the frequency of recurrence. |
