Submission: June 21, 2019;; Published: July 05, 2019
*Corresponding author: Gontumukkala Chalapathi, Department of Pediatrics, KIMS Hospital, Kurnool, Andhra Pradesh, India
How to cite this article: J Deepti, Gontumukkala C, Vasu B, M Hima Bindu , Chettipally V S. A Rare Case of Isolated Trichobezoar in Jejunum
Presenting as Obstruction - A Case Report. JOJ Case Stud. 2019; 10(3): 555786. DOI: 10.19080/JOJCS.2019.10.555786.
Introduction: A trichobezoar is a rare condition that starts with ingestion of hair which gets accumulated and forms a mass that causes obstruction. This is most commonly seen in girls and stomach being the most common site. Rarely, seen as isolated mass in jejunum or the stomach mass may extend to jejunum which is then referred as Rapunzel syndrome.
Case report: This is a case of an 8yr old girl who presented with vomiting’s and pain abdomen consistent with intestinal obstruction. No history of trichotillomania or trichophagia. Exploratory Laparotomy and Enterotomy revealed a 7×5cm mass in jejunum with no gastric component.
Conclusion: Trichobezoar is a rare surgically treatable condition. They should be considered in girls presenting with symptoms of obstruction. Parental counseling and psychotherapy should be mandatory in follow-up which help in preventing relapses. With high level of suspicion, prompt diagnosis and treatment, trichobezoars have a good prognosis.
A trichobezoar is a mass formed by ingestion and accumulation of undigested hair inside the gastrointestinal tract. Stomach is the most common site which may extend to duodenum as well as jejunum, which is then referred as Rapunzel Syndrome. Incidence of trichobezoar in paediatric population is around 0.4% . It is seen typically in girls usually with a history of trichotillomania and trichophagia. Affected children may remain unnoticed until it causes obstructive symptoms. We hereby report a unique case of isolated jejunal trichobezoar presenting as intestinal obstruction in an 8yr old girl.
An 8yr old girl presented with complaints of pain abdomen for 6 days, vomiting’s for 6 days initially non bilious and bilious for 3 days and not passed stools for 4 days. History of anorexia and weight loss was present. The child denied history of trichophagia but had patchy alopecia 2 years before this presentation for which she was treated. On examination, child was malnourished with moderate dehydration and pallor. Abdomen was tender all over with no palpable mass. Laboratory investigations showed anaemia (Hb-7%), with marked leukocytosis (TLC – 21000cells/cu mm). USG revealed prominent fluid filled jejunal loops. CECT abdomen was suggestive of Subacute intestinal obstruction with dilated fluid filled ileal and jejunal loops with minimal ascites. Child was subsequently taken for exploratory laparotomy which revealed an intraluminal mass in mid jejunum with dilated proximal jejunum (Figure 1). Enterotomy was done with vertical incision over the mass (Figure 2) and a trichobezoar of 7×5cm was removed (Figure 3). Child recovered well with an uneventful postoperative period. Child was discharged on 8th postoperative day with psychiatric referral.
Trichobezoars are concretions of hair, a rare entity, usually
seen in girls, stomach being the most common site. It can be seen
in as young as 3 years old . Trichobezoar occurs in 1% of the
patients with trichophagia . However, they may appear even
years after stopping trichophagia . Psychiatric illness and
mental retardation may be seen in about 10% of the children
. Smooth surface of hair makes it resistant to propulsion
by peristalsis and gets retained slowly developing into a mass
. Gastric bezoars tear into pieces and get impacted in small
intestine leading to obstruction. Extension from stomach to
intestines is referred to as Rapunzel Syndrome. The gastric
acid causes denaturation of hair changing its colour to black
irrespective of their original colour . A positive family
history for psychiatric illnesses and consuming non nutritional
substances may be seen in some children.
Recently, the incidence has been increasing with varied
presentations. Trichobezoars may go undiagnosed until the size
increases sufficiently to cause symptoms of obstruction. It may
also present as volvulus or intussusception [7,8]. Clinically, 70%
of the children present with chronic or recurrent pain abdomen,
nausea and vomiting is seen in 65%, 38% have anorexia and
weight loss, altered gastrointestinal motility manifesting as
diarrhoea or constipation in 33% of the children . A welldefined
abdominal mass is generally present which is mobile
in 90% of the cases and may indent (Lamerton’s sign) . If
left untreated trichobezoars grow and undergo complications
including mucosal erosion, ulceration and perforation. These are
the result of reduction in blood supply to mucosa of stomach and
intestine. They may also lead to intestinal obstruction, volvulus,
biliary perforation, intussusception in few children.
A high suspicion is required to diagnose trichobezoar
preoperatively due to nonspecific presentation. A positive
history of trichophagia along with radiological imaging plays
an important role in diagnosis. Ultrasound abdomen is used as
initial modality in diagnosing which shows a pathognomonic
shadow between bezoar and bowel wall. CECT is the preferred
modality, a heterogeneous mass with mottled gas pattern
suggests a bezoar . It helps in delineating the size and
extension. Upper GI Endoscopy is the gold standard for gastric
Management is mainly surgical intervention and the
approach depends on the size and location. Laparotomy or
laparoscopy is the best treatment modality. Small bezoars can
be retrieved by laparoscopy but large ones and those with
complications require open procedure as they are difficult
to remove. In our case, trichobezoar was diagnosed intra
operatively. Laparoscopy was preferred in our case due to its
location in jejunum and a decent size of bezoar. Endoscopic
retrieval by fragmentation is successful for initial and small
gastric bezoars. Pharmacotherapy is inconsistent and some
may respond to SSRIs (Selective Serotonin Reuptake Inhibitors).
Behavioral modification and psychotherapy are effective and
recommended in all patients to prevent relapses. Complications
postoperatively include wound infection, perforation, paralytic
ileus, fecal leakage from laparotomy wound . Diagnosis
and surgical intervention at right time prevents bowel and
mesenteric ischemia and gangrene.
Trichobezoars are rare, benign, surgically treatable condition.
It is an important differential diagnosis to be remembered
in cases of chronic abdominal pain and epigastric mass. Early
diagnosis helps in preventing complications. Recurrence is
uncommon. Parental counseling and psychotherapy should be
mandatory in follow-up which help in preventing relapses. Most
cases are stable and have a favorable outcome. With high level of
suspicion, prompt diagnosis and treatment, trichobezoars have
a good prognosis.