Picture of the Month—Diagnosis

Abdominal radiography revealed a mass in the stomach (see Figure 1 and Figure 2). Open surgical resection of the stomach revealed a trichobezoar (hair bezoar) (see Figure 3) and evidence of gastritis. Upon further inquiry with the family, we learned that the child had had a history of trichotillomania since 2 years of age; however, at the time, she had no signs of alopecia. Within days of the surgical removal of the bezoar, the child's appetite improved and she quickly gained weight. Her anemia was attributed to iron deficiency from chronic blood loss associated with gastritis as well as poor oral intake. Following surgery, outpatient child psychiatry consultation was arranged.

The accumulation of foreign ingested material in the form of masses or concretions may result in a gastric bezoar.¹ Bezoars are classified according to their composition: phytobezoars, trichobezoars, and pharmacobezoars. Phytobezoars, composed of vegetable matter, are the most common type with the persimmon fruit (diospyrobezoar) accounting for the majority of cases. Banana seeds have also been reported.² Trichobezoars, composed of hair, typically occur in young women and girls with psychiatric disorders such as trichotillomania (hair pulling) and trichophagia (hair eating), which usually precede trichobezoar formation. Pharmacobezoars, composed of ingested medications, have become increasingly recognized from such medications as iron, antacids, theophylline, enteric-coated aspirin, nifedipine, sodium alginate, and sucralfate. Bezoars composed of a variety of other substances, such as shellac, fungus, milk curd, tissue paper, cement, vinyl gloves, and Styrofoam cups, have been described.³

Trichobezoars form in patients with trichotillomania and trichophagia. They begin as retained hairs between the gastric folds; the hair is then denatured by gastric acid, becomes black (regardless of hair color), and combines with food to form an enmeshed mass. Trichobezoars become colonized by bacteria, resulting in a foul smell. A small number of patients have been reported in whom the gastric trichobezoar has a long tail and extends throughout the small bowel to the cecum. This condition, known as the Rapunzel syndrome, occurs almost exclusively in young girls.^4-6

Many affected patients remain asymptomatic for many years and develop symptoms insidiously. Common complaints include abdominal pain, nausea, vomiting, early satiety, anorexia, and weight loss. Gastrointestinal bleeding, leading to iron deficiency anemia, is a common presentation because there is a high association of gastric ulcers or gastritis in patients with bezoars. The ulcers may be due to peptic ulcer disease or pressure necrosis. Although many bezoars become quite large, gastric outlet obstruction is an uncommon presentation.

Bezoars have rarely been associated with a vast array of other gastrointestinal complications. These include gastrointestinal perforation, peritonitis, protein-losing enteropathy, steatorrhea, pancreatitis, intussusception, dysphagia, obstructive jaundice, appendicitis, constipation, and pneumatosis intestinalis. These other gastrointestinal complications may occur either when “the Rapunzel,” or the string of a long tail of hair, extends into the small intestine or when an embolus of hair lodges in the small intestine, becoming the lead point for obstruction or intussusception.^6,7

On physical examination, most patients with a gastric bezoar may have minimal findings except for an occasional painless abdominal mass or halitosis. Pallor may accompany anemia. Parents may report that the child eats frequent small meals with early satiety. Patients with trichobezoars may have patchy areas of alopecia, a result of the accompanying trichotillomania.

Bezoars are usually discovered as an incidental finding in a patient with nonspecific symptoms. Abdominal radiograph with or without barium, abdominal ultrasound, or computed tomographic scan may show the bezoar as mass or a filling defect. Therapy for bezoars should be tailored to the composition of the concretion and to the underlying pathophysiologic features. Removal of the bezoar does not alleviate the underlying process that precipitated the bezoar. Preventive therapy should be implemented to avoid a reported 14% recurrence rate. Patients should be encouraged to seek psychiatric evaluation, especially in children with trichobezoars.

Correspondence: Kathryn S. Moffett, MD, Department of Pediatrics, West Virginia University, HSC-9214, Morgantown, WV 26506-9214 (kmoffett@hsc.wvu.edu).

Accepted for Publication: September 14, 2005.