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Special Feature
October 20, 2008

Image of the Month—Diagnosis

Arch Surg. 2008;143(10):1020. doi:10.1001/archsurg.143.10.1020
Answer: Bezoars

Bezoars are infrequent causes of gastrointestinal symptoms. They are classified as phytobezoars, trichobezoars, and pharmacobezoars according to their content. A trichobezoar is usually composed of human hair or rarely a threadlike substance from an animal, carpet, cloth, or doll; the substance is slippery, is resistant to digestion in the gastrointestinal tract, and always aggregates in the stomach. The gross appearance (Figure 2) of trichobezoars is black and meshlike, and their smell is foul after exposure to gastric secretions.1

Figure 2.
The gross appearance of the trichobezoars in the stomach (asterisk) and small bowel (arrow).

The gross appearance of the trichobezoars in the stomach (asterisk) and small bowel (arrow).

Trichobezoars can result in gastric outlet obstruction or small-bowel obstruction. If the trichobezoar extends from the stomach into the small bowel or from the small bowel to or beyond the ileocecal valve, then Rapunzel syndrome ensues. The separated fragment of the trichobezoar may cause small-bowel obstruction; however, trichobezoars are a rare cause of gastric outlet or small-bowel obstruction, mostly among persons with trichotillomania and trichophagia of several years' duration.2 Other complications include gastric ulcer, bowel perforation, intussusception, or rarely protein-losing enteropathy, iron-deficiency anemia, or jaundice.1

A patient with a trichobezoar who is in search of medical treatment may present with young age, epigastric pain, nausea, vomiting, halitosis, hair loss, poor intake, and body weight loss over a long time. Physical examination may reveal a palpable abdominal mass, distention, tenderness, or malnutrition, but only hair loss is specific for the diagnosis of trichobezoar.3 Trichotillomania and trichophagia are not usually disclosed at the first consultation. However, recognition of the cause of a trichobezoar during follow-up treatment is important because recurrence is possible.

An abdominal radiograph of a patient with a bezoar could show a mottled mass lesion in the distended stomach or signs of small-bowel obstruction. Computed tomography is a good tool to demonstrate a possible diagnosis of bezoar because of the specific appearance as well as the location and, more important, the possible multiplicity of bowel obstruction, that is, the synchronous lesions (Figure 1). Other complications can include bowel perforation, peritonitis, or abscess formation. The findings of bezoar on computed tomography are consistent with a meshlike mass with heterogeneous density and air trapping without connection to the gastric wall in the stomach or, less frequently, in the small bowel.4

Figure 1.
The abdominal radiograph shows a large filling defect in the stomach, outlined by the water-soluble contrast medium (arrows). Inset, The reformatted coronal computed tomographic scan reveals the bowel obstruction with large fecal material–like masses impacted in the stomach (asterisk) and small bowel (arrow).

The abdominal radiograph shows a large filling defect in the stomach, outlined by the water-soluble contrast medium (arrows). Inset, The reformatted coronal computed tomographic scan reveals the bowel obstruction with large fecal material–like masses impacted in the stomach (asterisk) and small bowel (arrow).

Our patient was diagnosed with bezoars in the stomach and ileum on computed tomography. She underwent laparotomy with gastrotomy and ileostomy to remove the trichobezoars and for decompression of the small-bowel obstruction. Two trichobezoars were found during surgery: one measuring 22 × 10 cm in the stomach and the other measuring 22 × 5 cm at 60 cm proximal to the ileocecal valve. Pica and trichotillomania were suspected by the psychiatrist. After discharge, the patient was monitored closely in the outpatient department uneventfully.

Surgical intervention is always necessary for removal of bezoars, although the minimally invasive method of endoscopic fragmentation and removal has been reported.1 Endoscopic fragmentation may be considered only if the size of the bezoar is small because there is a risk of the separated portions of bezoars entering the small bowel during the procedure and resulting in small-bowel obstruction. If the bezoar is large or there are multiple bezoars, laparotomy is effective for removal of all of the bezoars and for relieving obstruction at the same time. Psychiatric consultation is also mandatory to prevent recurrence of the behavior.

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Article Information

Correspondence: Shyh-Jye Chen, MD, PhD, Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan (james@ha.mc.ntu.edu.tw).

Accepted for Publication: January 21, 2007.

Author Contributions:Study concept and design: Lin and Chen. Acquisition of data: Teng. Analysis and interpretation of data: Teng and Liu. Drafting of the manuscript: Teng and Liu. Critical revision of the manuscript for important intellectual content: Teng, Liu, Lin, and Chen. Administrative, technical, and material support: Liu. Study supervision: Lin and Chen.

Financial Disclosure: None reported.

References
1.
Coulter  RAntony  MTBhuta  PMemon  MA Large gastric trichobezoar in a normal healthy woman: case report and review of pertinent literature. South Med J 2005;98 (10) 1042- 1044
PubMedArticle
2.
Bouwer  CStein  DJ Trichobezoars in trichotillomania: case report and literature overview. Psychosom Med 1998;60 (5) 658- 660
PubMedArticle
3.
Lynch  KAFeola  PGGuenther  E Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department. Pediatr Emerg Care 2003;19 (5) 343- 347
PubMedArticle
4.
Gayer  GJonas  TApter  S  et al.  Bezoars in the stomach and small bowel: CT appearance. Clin Radiol 1999;54 (4) 228- 232
PubMedArticle
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