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Unsuspected Trichobezoar in a Child with Short Hair

Meir General Hospital Sapir Medical Center Kfar-Saba 44281, Israel

Trichobezoars usually occur in young girls who swallow their own hair [1]. Typical findings in these patients include a palpable abdominal mass and alopecia. We recently encountered a case of a young boy with short hair and no alopecia, who presented with small-bowel obstruction caused by trichobezoar.

A 9-year-old mentally retarded boy presented with a 2-day history of bilious vomiting and loss of appetite. Physical examination findings were normal. Abdominal radiographs showed distention of small-bowel loops with air-fluid levels (Fig. 2A). Upper gastrointestinal barium study revealed distended proximal small-bowel loops caused by an intraluminal mass in the jejunum (Fig. 2B). Because the boy had short hair without signs of hair loss, trichobezoar was not initially suspected. At exploratory laparotomy a 5 x 10 cm trichobezoar was evacuated from a jejunal loop, 50 cm distal to the ligament of Treitz. Postoperative discussions with the family revealed that the boy was habitually pulling and chewing his older sister's hair.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —9-year-old boy with small-bowel obstruction caused by trichobezoar. Abdominal radiograph with patient erect shows distention of small-bowel loops with air-fluid levels.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —9-year-old boy with small-bowel obstruction caused by trichobezoar. Upper gastrointestinal barium study shows intraluminal mass in jejunum causing proximal small-bowel obstruction.

Bezoars are concretions formed in the stomach or the intestine of various foreign or intrinsic substances. The most common types are trichobezoars, composed of hair, and phytobezoars, containing fruits and vegetables [2]. Long-standing ingestion of hair causes a mass formation in the stomach that may extend into the small bowel (i.e., the "Rapunzel syndrome") or completely dislodge from the stomach, migrate to the small bowel, and cause small-bowel obstruction [2, 3]. Signs and symptoms of bezoars include vomiting, loss of appetite, weight loss, and abdominal pain. Complications include ulcer formation, bowel perforation, small-bowel obstruction, and intussusception [1, 4]. Typical findings in these patients include an abdominal mass and alopecia. The diagnosis of bezoar may be suspected from an abdominal radiograph, that shows a mottled mass. Barium examination may reveal an irregular intraluminal mass, which may confirm the diagnosis [3, 5]. A recent report suggested the usefulness of CT in the preoperative diagnosis of bezoars in patients with small-bowel obstruction [5].

Because the clinical presentation and radiologic findings were atypical in our patient, trichobezoar was not initially suspected. Radiologists should include trichobezoar in the differential diagnosis of small-bowel obstruction even in young boys with short hair and no evidence of hair loss.

References

1. DeBakey M, Ochsner A. Bezoars and concretions: a comprehensive review of the literature with an analysis of 303 collected cases and presentation of an 8 additional cases. Surgery 1939;5:934 -963
2. Wolfson PJ, Fabius RJ, Leibowitz AN. The Rapunzel syndrome: an unusual trichobezoar. Am J Gastroenterol 1987;82:365 -367[Medline]
3. Newman B, Girdany BR. Gastric trichobezoars: sonographic and computed tomographic appearance. Pediatr Radiol 1990;20:526 -527[Medline]
4. Harris VJ, Hanley G. Unusual features and complications of bezoars in children. AJR 1975;123:742 -745
5. Gayer G, Jonas T, Apter S, et al. Bezoars in the stomach and small bowel: CT appearance. Clin Radiol 1999;54:228 -232[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Konen, O. Articles by Shapiro, M. Search for Related Content PubMed PubMed Citation Articles by Konen, O. Articles by Shapiro, M. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?