Clinical Profile:

•A 10 year old girl was admitted with abdominal pain and vomiting since four days.

•No history of fever.

•No h/o altered bowel habits.

• Past history of similar episodes and h/o jejuno-jejunal intussusception for which laparoscopic reduction was attempted few days back.

Radiological findings

•Present USG: long segment small bowel intussusception.

•Decision to do barium studies was made.

A diagnosis of a bezoar was made. . Upon questioning, the parents gave history of trichophagia.

Fig. G and fig. H shows well defined large mottled lesion with air and soft tissue attenuation filling the distal stomach and antrum.

Small bowel loops appear edematous.

Operative findings:

Intraoperative findings confirmed the imaging findings.

This was a case of gastric trichobezoar extending upto the ileal loops (Rapunzel syndrome )

Discussion:

•Bezoars are ingested foreign materials that accumulate within the gastrointestinal tract.

•Classification:

• Trichobezoars(composed of hair)

• Phytobezoars (composed of fruit and vegetable fibres).

•Lactobezoar (milk products)

•Pharmacobezoar

•Predisposing factors:

•Psychiatric illness

•Inadequate chewing

•High-fiber diets

•Previous gastric surgery.

Small-bowel obstruction is the most frequent clinical presentation of phytobezoars.

•If the hair from a gastric bezoar extends into the jejunum, it is then considered Rapunzel syndrome.

•This form is more dangerous because of the risk of the bezoar tail breaking off and causing intestinal obstruction.

•Bezoars usually form in the stomach and can pass into the small bowel where they can cause obstruction.

•Most bezoars are found in patients with a history of previous gastric surgery.

Imaging

•Abdominal X-ray: Gives us the first clue of intestinal obstruction. The radiographic image of a bezoar is not uniquely characteristic and can be mistaken for an abscess or presence of faeces.

•Barium studies are used to confirm the bezoar which shows persistent filling defect and retention of barium.

•Ultrasonography: sonographic visualization of an intraluminal mass with a hyperechoic arclike surface and a marked acoustic shadow is suggestive of a bezoar. Bezoar-induced obstruction should be distinguished from gallstone ileus.

•CT :Small bezoars are rounded or ovoid, tend to float on the water-air surface surrounded by the gastric contents, and show lower density than food particles.

•Large bezoars tend to fill all the lumen, exhibiting air bubbles diffusely distributed throughout the mass.

•The imaging findings in CT of gastrointestinal bezoars: a well-defined shape, round or ovoid, intraluminal mass with a mottled air pattern at the site of the obstruction and floating fat-density debris in the proximal dilated loops, being necessary its differentiation from the small-bowel feces.

Treatment options include:

• Endoscopic retrieval

•Laparoscopic

•Laparotomy

•Endoscopic retrieval seems to be unsuccessful because bezoars are usually not detected until they reach a fairly large size.

•Laparoscopic removal of bezoars is also limited by the size of the bezoar and many large bezoars cannot be removed laparoscopically.

•Therefore, most commonly bezoars are removed via gastrostomy.

•The most common type of bezoar is trichobezoar and its most effective treatment is to prevent the recurrence which is achieved by long term psychiatric follow up.

References:

1.American Journal of Roentgenology. 2001;177: 65-69. 10.2214/ajr.177.1.1770065

2.Verstanding AG, Klin B, Bloom RA, Hadas I, Libson E. Small bowel phytobezoars: detection with radiography. Radiology 1989; 172:705-707

3.I. lópez blasco, S. Paz Maya, D. Soriano Mena, J. P. Ruiz Gutierrez, A. Llanes Rivada, D. Dualde-Beltrán, R. Dosdá-Muñoz, J. Palmero; Valencia/ES10.1594/ecr2013/C-1542

4.LT Amy Barrows; LCDR Tyler Vachon; CDR Richard C. Campin; CAPT Romeo C. Ignacio Jr., 2015; 80, 10:e1136.

Acknowledgement:

We are grateful to the Department of Surgery at our institution for providing the intraoperative photographs.