Woman With Chronic Abdominal Pain, Weight Loss, and Palpable Abdominal Mass

Abstract

Question: A 43-year-old woman with a past medical history of prior morbid obesity body mass index 53 (current body mass index 24), well-controlled type II diabetes on metformin presented with a 1-year history of early satiety, worsening reflux symptoms, abdominal pain, 163 lbs weight loss, and abdominal distension. She was evaluated by her primary physician 1 year prior for similar symptoms, was referred for gastroenterology evaluation but the patient never followed up with her appointments and was lost to follow-up. She presented to the emergency department with acute exacerbation of abdominal pain, nausea, nonbilious emesis, and progressive oral intolerance. Her vital signs were within normal limits; physical examination was remarkable for alopecia and temporal wasting, a palpable nontender tense epigastric and pelvic mass with associated left axillary and left inguinal adenopathies. Her laboratory workup was notable for microcytic hypochromic anemia, with anysocitosis, low iron levels with elevated haptoglobin; white blood cells, folate, and albumin were normal. The rest of the workup, including occult blood testing, was normal. An abdominal computed tomography scan demonstrated severe gastric distention with a large heterogeneous mass with a swirling appearance and multiple foci of gas measuring approximately 18 × 21 × 10 cm displacing the left kidney and an enlarged myomatous uterus containing a dominant partially calcified fibroid measuring up to 13 cm (Figure A, B). What is the diagnosis and approach to management of this patient? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. This patient presented with a rare case of Rapunzel syndrome. Upon further history, the patient reported trichotillomania and trichophagia since she was 5 years old. Computed tomography scan findings were consistent with a large heterogeneous mass within the stomach lumen consistent with bezoar. The size of the bezoar was not amenable to endoscopic extraction; therefore, the patient underwent a laparotomy with a midline 5-cm incision, an Alexis O Wound Protector (Applied Medical, Rancho Santa Margarita, CA) was used to prevent spillage of gastric contents and bezoar fragments into the abdominal cavity.1Obinwa O. et al.Rapunzel syndrome is not just a mere surgical problem: a case report and review of current management.World J Clin Cases. 2017’16; : 50-55Crossref PubMed Google Scholar, 2Fallon S.C. Slater B.J. Larimer E.L. et al.The surgical management of Rapunzel syndrome: a case series and literature review.J Pediatr Surg. 2013; 48: 830-834Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Hall J.D. Shami V.M. Rapunzel’s syndrome: gastric bezoars and endoscopic management.Gastrointest Endosc Clin N Am. 2006; 16: 111-119Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar A longitudinal anterior gastrotomy was performed and removal of the gastric trichobezoar was completed (Figure C and Supplemental Video). eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3ODQ0ZGQ0YTBhYzMzMWI2YTJiMWI2ODE5YWEyOWYwMSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODgyMTA4fQ.qT5Tmuw2vrDBVrGQDje4LUSu3V-Qw4Hs07X_13l4-sEV33Tmu4vbs0f326E53X_7d92aSrDZ7kvlknyR6k5Zsudig6mqF19lhqkydYI58nWtTrLfdqlNTlZrTFcuUvDou7D-mUQU3Cwlp7jnLPaGEm4GLupL_qcil91ftYtwsITw1EbZcDC2CUHSO7f86upSkH14FKj6P9oPlORIaxUftBvZovWMfayACLpWZguIbkBrZvIcSlLSnsqDu902liAA0lok10l_h4DSRNyHqz8vNxkVXMp9_r1Alkqdp4EjjC5CNrt5w2ZqeAm067J7maRqgEi55d3OTncC9D5TEZALpQ Download .mp4 (5.63 MB) Help with .mp4 files Video