Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1996  |  Volume : 2  |  Issue : 1  |  Page : 53-55
Unusual cause of epigastric mass

Department of Surgery, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

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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:

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 Top

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 Top

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 Top

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.  Back to cited text no. 1    
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.  Back to cited text no. 2    
3.Sharma V. Sharma ID. Unusual pretention of trichobezoar. Indian Pediatrics 1990;27:187-9.  Back to cited text no. 3    
4.Sandhu NPS, Gupta NM. Gastric Perforation (letter). Indian J Gastroenterol 1989:8:302-3.  Back to cited text no. 4    
5.Newman B. Girdany BR. Gastric Trichobezoars - Sonographic and Computed Tomographic Appearance. Pediat Radiol 1990;20:526-7.  Back to cited text no. 5    
6.Gossum AV, Delhay D, CremerM. Failure of Nonsurgi­cal Procedures to Treat Gastric Trichobezoars. Endos­copy 1989;21:113.  Back to cited text no. 6    
7.Soehendra N. Endoscopic Removal of Trichobezoar. Endoscopv 1989:21:201.  Back to cited text no. 7    
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.  Back to cited text no. 8    
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.  Back to cited text no. 9    

Correspondence Address:
HAR El-Musharaf
Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 19864843

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