Gastric Trichobezoar with Extension into Duodenum

Plain radiograph shows a large mottled soft tissue density with crescent of air surrounding it. Soft tissue mass displaces the bowel loops peripherally on all sides. On barium study there is increase in caliber of stomach. A large irregularly coated mass is seen which changes its position with the change in position of patient suggestive of the intraluminal nature. On ultrasound a linear echogenic band was seen with complete distal shadowing. On computed tomography, a large completely intraluminal mass with a whorled appearance and coating of oral contrast on the surface of the mass was noted [Figure - 4]. The mass extended up to the second part of the duodenum. At surgery 4.1 kg trichobezoar in a cast of stomach and proximal duodenum was removed [Figure - 5].

Bezoars are persistent concretions of foreign matter composed of accumulated ingested material in stomach and small intestine . Indigestion, gastric hypomotility, gastric surgeries like Bilroth I & II, overindulgence in food with high fiber content, and in case of trichobezoar psychiatric illness predisposes to the formation of bezoars [1].

The clinical manifestations depend on the location of the bezoar. Gastric bezoar may cause dyspepsia, nausea, vomiting (64%), colicky abdominal pain (70%), alteration of bowel habits (32%), anorexia, weakness and weight loss. In addition to vague abdominal discomfort bezoar may be associated with gastric outlet obstruction, ulceration and perforation. Distal extension of bezoars can lead to obstructive jaundice, acute pancreatitis, protein losing enteropathy, steatorrhea and mechanical small bowel obstruction alone or with perforation and Rapunzel syndrome. Clinical examination may reveal alopecia and halitosis due to decomposition and fermentation of fats trapped in the interstices of the bezoar. A well-defined smooth, firm, mobile epigastric mass is found in 88% of patients, and there may be tenderness in 70% of patients [2].

Various types of bezoar include phytobezoar (undigested fibers, seeds, persimmons, vegetable skins), trichobezoar (hair), medicobezoar (undigested tablets, commonly antacids), lactobezoar (high density undigested milk), Picobezoar (sand), and unnamed like candida albicans bezoar formed in stomach after Bilroth surgery [1],[3].

When the bezoar extends into the small intestine, it is called Rapunzel syndrome [3].

On plain radiograph few patient show typical mottled gas pattern of trichobezoar. This pattern is mimicked by faeces and abscess[4].

On ultrasound, it produces a sharp echogenic band with distal clear shadowing. This can be attributed to multiple tiny interfaces between the smooth, compressed, compact mass and the entrapped air and food debris[2]. The marked acoustic shadowing behind the echogenic band produced by a bezoar is different from "dirty" shadowing generated by ingested gas and food within the stomach [4].

CT may be considered the imaging technique of choice for confirming a diagnosis of gastrointestinal bezoars [4]. Plain abdominal CT 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 [2]. Bezoars, especially those located in the stomach, may go undetected if the CT scans are printed at standard abdominal soft-tissue window setting (level, 40 H; width, 350 H). Modifying the window setting by reducing the level to-100 H makes it possible to better identify the characteristic appearance of bezoars [4].

Surgery is the treatment of choice for the trichobezoar. Endoscopic fragmentation and removal can be tried but difficult with large masses [3].