Gastric bezoar refers to the presence of gastric foreign body consisting of different substances, increasing in size by accumulation and mixing of these substances. This is due to the impossibility of evacuation of these substances by the stomach . The mechanism of accumulation is still mostly related to gastroplegia .
We report the case of a young patient who was diagnosed with trichobezoar in the face of an acute intestinal obstruction.
The interest of this observation is to illustrate the role of CT in the diagnosis of this rare entity.
A 16-year-old girl presents to the emergency department with abdominal pain and a three-day history of gas and fluid retention in the setting of AEG. An appendectomy was performed on her two years ago.
The clinical examination revealed a depressed, asthenic and malnourished patient. Abdominal palpation revealed an epigastric voussure. She presented a huge scalp peeling.
The biological workup showed microcytic anemia at 9g/dl and hyperleukocytosis.
The PSA showed hydroaeric levels of the gallbladder type.
In view of this acute intestinal occlusion syndrome, and the notion of appendectomy, the patient underwent an abdomino-pelvic CT scan which revealed a large intragastric mass, heterogeneous in spontaneous contrast and unchanged after injection of the iodinated contrast medium (Figure 1). There was a second mass with the same characteristics at the level of the small intestines without any sign of suffering (Figure 2).
Figure 1: CT in axial slices before (a,b) and after PDC injection (c,d) Distended stomach with presence of an intraluminal heterogeneous mass, seat of air bubbles, not attached to the wall and not modified by contrast (star).
The diagnosis of gastric trichobezoar with a migrated portion in the ileum was evoked and confirmed intraoperatively (Figure 3).
The therapeutic management consisted of surgical removal of the trichobezoar and its ileal portion.
The patient was subsequently referred to the psychiatric department for management of her depressive state.
Figure 2: CT in axial sections before (a) and after injection of PDC (b) Second mass intraluminal in the bowel, heterogeneous, with air bubbles, not attached to the wall and not modified by contrast (yellow arrow).
Figure 3: Intraoperative images. A- gastric trichobezoar after its extraction. B- second portion migrated to the small intestine responsible for an obstruction of its lumen without sign of suffering.
Trichobezoar refers to the presence of ingested substances (hair, hairs or fibers) usually in the stomach and very rarely in the small intestine.
Its exact prevalence is not known, many patients being asymptomatic. They are most often observed in girls (90% of cases), with a peak incidence in adolescence [3,4].
A background of psychological disorders is often associated, including depression, mental retardation, trichotillomania and trichophagia .
Decreased peristalsis and gastric stasis favor the development of trichobezoar .
The extension of the gastric trichobezoar into the small intestine through the pylorus and sometimes into the transverse colon constitutes the Rapunzel syndrome .
Clinically, gastric trichobezoar is most often asymptomatic. The mode of discovery is varied, but in general it is a picture of altered general condition with anorexia, weight loss and malabsorption syndrome associated with digestive signs such as abdominal pain, transit disorders and postprandial vomiting [5,7].
The clinical examination must be careful to look for the notion of trichophagia.
The discovery can be made in front of an intestinal obstruction as in our patient. It may also be due to digestive hemorrhage, perforation, and peritonitis [6,14]. The usual site of intestinal obstruction is the terminal ileum.
Medical imaging allows positive diagnosis. Abdominal ultrasound demonstrates an intragastric mass, separated from the wall, heterogeneous hyperechoic with a clear posterior shadow cone [8,9].
Abdominal and pelvic CT scan with and without contrast injection allows a good characterization of this mass and to make the diagnosis. It shows a gastric distension with a large intraluminal mass, heterogeneous, of mixed density, mobile, with air trapping and without modification by the PDC.
The existence of intra-lesional air particles confirms the diagnosis.
The CT scan allows to specify its exact location as well as its extension away from the stomach, but also to differentiate it from fecal matter and from other pathologies such as neoplasia [10-13].
Treatment is based on the removal of the trichobezoar either by endoscopic or surgical means, which is most often used.
Psychotherapy is indicated to avoid recurrence.
The diagnosis is often easy when there is a combination of anamnestic arguments and medical imaging.
The CT scan allows to specify the extension of the trichobezoar and to eliminate the existence of other synchronous localizations and to look for complications.
Conflict of interest: The authors declare that they have no conflict of interest.