Unusual cause of epigastric mass

HAR El-Musharaf; AI Al-Mohareb

Home

About us

Instructions

Submission

Advertise

Contact

Users Online: 686

CASE REPORT

Year : 1996 | Volume : 2 | Issue : 1 | Page : 53-55

Unusual cause of epigastric mass

HAR El-Musharaf, AI Al-Mohareb
Department of Surgery, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Click here for correspondence address and email

How to cite this article:
El-Musharaf H, Al-Mohareb A I. Unusual cause of epigastric mass. Saudi J Gastroenterol 1996;2:53-5

How to cite this URL:
El-Musharaf H, Al-Mohareb A I. Unusual cause of epigastric mass. Saudi J Gastroenterol [serial online] 1996 [cited 2022 Jul 3];2:53-5. Available from: https://www.saudijgastro.com/text.asp?1996/2/1/53/34042

Trichotillomania is the irresistible urge to pull one's hair from the scalp, but eyelashes, eyebrows, axillary or pubic hair may also be removed. Most cases start in adolescence and women are affected more than men. Trichotillomania may be associated with a variety of psychiatric disorders. It is difficult to treat, but sometimes, responds to behavioral treatment ^[1],[2] . Some patients save their hair and eat them (Trichophagia). Trichobezoar usually occurs in young girls, who swallow their own hair over a prolonged period, forming an intraluminal mass of hair intermingled with food debris and having the shape of the stomach.

Case Report

A 15-year-old Saudi girl presented with vomiting and abdominal colic once or twice a day for a two-month duration. The vomitus contained undigested food and usually occurred in the evening. She noticed epigastric swelling associated with anorexia and weight loss.

Examination revealed a pale thin girl weighing 34 kgs with a firm, smooth, non-tender, mobile epigastric mass, which extended down below and to the right of the umbilicus. Hematological investigation showed a picture of microcytic hypochromic anemia. Plain abdominal x-ray [Figure - 1] showed a mottled mass similar in appearance to a food-filled stomach. While abdominal ultrasonography was inconclusive, CT scan showed intragastric multiple concentric rings appearance with entrapped air and debris [Figure - 2].

On upper gastrointestinal endoscopy, a hair bezoar was occupying the gastric lumen. Surgical gastrotomy was performed and confirmed the endoscopic findings. The large bezoar (830 gms) was enucleated easily [Figure - 3].

The postoperative recovery was uneventful and the patient was referred for psychiatric consultation. Over the following two years the patient was well and asymptomatic.

Discussion

Hair-pulling has been interpreted as a tensionreducing habit; a masochistic behavior, a symbol of fear of castration, an expression of rage, a denial of femininity and a masturbatory equivalent. None of these explanations is convincing. It has also been reported to be associated with mental retardation^[1] .

Trichobezoars are usually asymptomatic or causing mild upper gastrointestinal symptoms, ranging from dragging and fullness in the upper abdomen to epigastric pain, which is the most frequent symptom. Periodic attacks of nausea and vomiting may occur. Complications of trichobezoar include gastric outlet obstruction, gastric ulceration and perforation. Ulceration is due to mechanical irritation of the gastric mucosa in addition to stasis gastritis. Intestinal obstruction and preforation were also reported ^[2],[3],[4] .

The diagnosis of trichobezoar is difficult, because history of hair ingestion is not usually obtained. Large quantities of ingested food can mimic the mottled appearance of gastric bezoar on plain abdominal films. The tools of investigation of abdominal mass include ultrasonography and/or computed tomography (CT scan). Ultrasonographic appearance of trichobezoar is rather characteristic. It appears as a clear intense acoustic shadowing behind an anterior hand of echogenicity in the region of the stomach. A heavily-calcified tumor can have a similar sonographic appearance ^[5] .

In CT scan, trichobezoar appears as intragastric multiple concentric rings with entrapped air and enmeshed debris and in our case, this dictated our next investigation, endoscopy ^[5] .

In barium studies, the appearance is the that of a mobile irregular coherent intraluminal mass, best seen in delayed films. False positive study is not uncommon, so we omitted this investigation and proceeded to endoscopy. In gastroscopy, the trichobezoars are black and tarry and endoscopic biopsy, yielding hair is pathognomonic ^[2] .

Nonsurgical procedures to treat trichobezoar remain to be evaluated further. Endoscopy procedures using a jet of water applied through the biopsy channel to break the bezoar has been unsuccessful^[6] . Soehendra reported endoscopic piecemeal removal of the trichobezoar in three sessions, each two-three hours. In the first two days, NdYg laser was used to cut the bezoar. He concluded that it is very tedious and needs the cooperation of the patient ^[7].

Extracorporeal shock-wave lithotripsy was tried by Gossum, et al ^[6] . The stomach was filled with gastrografin to locate the mass and to create a liquid interface around the mass. One hundred shock waves per minute, up to a total of 3,000 shock waves, were applied. A gastroscopy, four hours later demonstrated that the bezoar was not damaged and there were small petechial lesions on the gastric mucosa ^[6] .

Ying-cai, et al., reported successful endoscopic fragmentation of gastric bezoars using a laserignited mini-explosive device in 31 patients. The mini-explosive was connected to the optic fiber of the laser and inserted through the biopsy channel of the gastroscope to contact the center of the bezoar. The laser instrument was switched on to ignite the mini-explosive. After three to five explosions, the bezoars were blown into pieces. They used triazoic lead into a small steel tube to make up the explosive device. The steel tube will not be affected if the explosive is less then 10 mg: they used 1.5 mg-explosive. After mini-explosions with 1.5 mg-explosive, by five explosions, the gastric content, containing lead has been aspirated out. -The surface of gastric mucosa may be slightly eroded. The fragments could be removed by snare, and most of them could be eliminated through the gastrointestinal tract^[8] .

The standard treatment remains surgical gastrotomy and removal of bezoar. Daughter-intestinal bezoars can be retrieved by retrograde milking in contrast to performing enterotomies.

To prevent recurrence, familial psychotherapy has to be considered. A few cases of trichotillomania have been treated by behavioral methods, but it has generally not been shown to be effective^[1] . The tricyclic antidepressant Clomipramine "Anafranil" may be of benefit in some cases ^[9]. In case of recurrence, the mass is to be left alone, as long as it is asymptomatic.

References

1.	Gelder M. Gath D, Mayoll R. Oxford Textbook of Psychiatry. Oxford, Medical Publications, Oxford University Press. Oxford, N.Y. 2nd edition, 1989:458-9.
2.	Salena BJ, Hunt RH. Bezoars. In Sleisenger MH, Fordtran JS. (Eds.) Gastointestinal disease . Pathophysiology, Diagnosis, Management, W. B. Saunder Company. Philadelphia, 1993;pp:758- 63.
3.	Sharma V. Sharma ID. Unusual pretention of trichobezoar. Indian Pediatrics 1990;27:187-9.
4.	Sandhu NPS, Gupta NM. Gastric Perforation (letter). Indian J Gastroenterol 1989:8:302-3.
5.	Newman B. Girdany BR. Gastric Trichobezoars - Sonographic and Computed Tomographic Appearance. Pediat Radiol 1990;20:526-7.
6.	Gossum AV, Delhay D, CremerM. Failure of Nonsurgical Procedures to Treat Gastric Trichobezoars. Endoscopy 1989;21:113.
7.	Soehendra N. Endoscopic Removal of Trichobezoar. Endoscopv 1989:21:201.
8.	Ying-cai H. Zhong-he G, Ying G. et al. Endoscopic Lithotripsy of Gastric Bezoar using a laser-ignited Miniexplosive Device. Chin Med J 1990:103:152-5.
9.	Swedo SE. Leonard HL, Rapoport JL. et al. A doubleblind comparison of clomipramine and desipramine in the treatment of trichotillomania. N Eng J Med 1989;321:497-501.