The Role of Endoscopy in a Patient with Recurrent Gastric Trichobezoar

Abstract

Purpose: Bezoars are accumulations of food and fiber in the alimentary tract. We present a case of a patient with recurrent trichobezoar in which endoscopic removal was tedious, time consuming, and ultimately unsuccessful. Methods: CASE:A 37-year-old female with medical history of hypertension and depression was admitted with nausea, vomiting and constipation for four days. It started 1 month ago with bloating, early satiety and weight loss of 40 pounds. Her medical history was significant for trichotillomania, and trichobezoar 18 months ago, which was removed successfully endoscopically over 2 days. On physical exam, she was of moderate built, malnourished, with a HR of 103 and BP of 156/91 mmHg. Scalp examination revealed sparse hair and red colored extensions that were missing in some areas. Abdominal exam was significant for mild epigastric fullness and tenderness on palpation. Labs were significant for a Hb of 10.4 g/dL. An abdominal radiograph showed a dilated loop of duodenum measuring 4.6 cm with mottled lucencies in the left upper quadrant. A CT confirmed a gastric bezoar within the stomach and small bezoars in the distal duodenum. She underwent upper endoscopy which showed a black hair bezoar. After spending 2 hours with multiple passes, less than 25% was removed and was referred for surgery. Two masses of hair 17 × 5 × 5 cm and 12 × 10 × 6 cm were removed via gastrotomy and a 6.5 × 3 × 3 cm was removed via ileal enterotomy. Results: DISSCUSSION: The term “bezoar” comes from the Arabic “badzhar” or the Persian “pahnzahr”, both meaning counterpoison or antidote. They are indigestible foreign body masses in the GI tract. They are classified into five types: phytobezoar, trichobezoar, pharmacobezoar, lactobezoar, and foreign body bezoars. Trichobezoar is seen in females less than 30 years of age. Ingestion of hair, (trichophagia), carpet, and clothing fiber are commonly implicated. They become trapped in the gastric folds forming a mass with symptoms of early satiety, weight loss, abdominal pain, and leading to obstructive symptoms. Plain radiographs and CT may be diagnostic, but endoscopy still remains the gold standard. Many approaches have been described such as enzymatic dissolution, to endoscopic removal with advanced instrumentation. Surgical removal via gastrotomy allows it to be removed in its entirety. Conclusion: CONCLUSION: Our case suggests that although endoscopic advances have been made, and success has been accomplished by some, their superiority to conventional techniques is still lacking. Gastrotomy should be considered over the tedious and time consuming endoscopic attempts. More ever, the patient should have psychiatric follow up to prevent recurrence, which our patient did not have, after her first episode.