HISTORY
Chelsea is a previously healthy 8-year-old girl who presents with vomiting (nonbilious), decreased appetite, epigastric pain, and frequent burping. The pain has been occurring intermittently for 1 month. The pain is worsened by eating but is alleviated when lying on her side. Mother reports no diarrhea and that the last bowel movement was 2 days ago. Mother also states that, recently, Chelsea has had anxiety at school and has started seeing a counselor.
ASSESSMENT
On physical examination, the provider found tenderness to the epigastric area and a firm palpable mass. Continued assessment finds dullness to percussion over mass, remainder of abdomen soft and nontender with active bowel sounds. Chelsea's vital signs were as follows: heart rate = 116, respiratory rate = 26, blood pressure = 122/78, and temperature = 37.2[degrees]C. The provider ordered a complete blood count, electrolyte panel, and a computed tomography (CT) scan (see Table 1).
What is Your Diagnosis?
What is the most likely diagnosis out of this list of differentials?
I. Small bowel obstruction
II. Constipation
III. Intussusception
IV. Foreign body
THE DIAGNOSIS IS:
IV. Foreign body (trichobezoar)
CASE PROGRESSION
The CT findings rule out small bowel obstruction, evidence of stool burden, or any evidence of invagination or telescoping of the intestine. CT findings indicate a distended stomach with a filling defect. Results also indicate a normal complete blood count and electrolyte panel. CT results in conjunction with an epigastric mass found on assessment indicate a foreign body.
RESOLUTION OF THE CASE AND PATIENT OUTCOME
Chelsea was taken to surgery, anesthetized, and prepped and draped in the usual sterile fashion. A vertical midline incision was made, and the stomach was opened through an anterior gastrotomy on the body of the stomach. A large trichobezoar was removed intact from the stomach (Figure 1). Palpation of the stomach revealed no other foreign bodies. There were no foreign bodies palpated in the duodenum. The gastrotomy was closed in two layers, and the viscera returned to the abdominal cavity. A sterile dressing was placed, and the procedure was terminated.
Chelsea is admitted to the surgical floor to monitor pain, encourage ambulation, and await return of bowel function. She is treated for pain with acetaminophen (15 mg/kg) and ibuprofen (10 mg/kg) as needed. Chelsea is encouraged to walk four to five times a day to help return bowel function. Psychology is consulted to evaluate stressors, manage anxiety, and assist with counseling to prevent reoccurrence of trichophagia and trichobezoar. When Chelsea is tolerating her regular diet, discharge education is provided to the mother that includes postsurgical site care and infection warning signs. Chelsea is encouraged to follow up with surgery providers in 1 month's time.
INFORMATION ABOUT THE DIAGNOSIS
Trichobezoar is an accumulation of ingested hairs in the gastrointestinal tract. In pediatric patients, it is primarily found in girls between the ages of 6 and 10 years (Aybar & Safta, 2011). Patients typically present to seek care with epigastric abdominal pain or mass, signs of obstruction, and nonbilious vomiting. Other clinical features include weight loss, poor appetite, and an underlying psychiatric disorder such as trichotillomania (hair pulling) and trichophagia (hair eating) (George, Samarasam, Mathew, & Chandran, 2013; Maharaj, Naidoo, Naidu, & Maharajh, 2013). Severe but rare complications of a trichobezoar can be intussusception, bleeding, and perforation (George et al., 2013; Maharaj et al., 2013). A trichobezoar should be suspected in patients who show signs of trichotillomania (hair pulling) and trichophagia (hair eating) such as patches of missing hair or bald spots (Matoq, Lee, & Salahuddin, 2017).
Medical providers should consider imaging to evaluate the extent of a bezoar. Ultrasound, radiology, and CT are common imaging techniques to evaluate patients with suspected bezoars. In addition, there are various methods for removal of a trichobezoar. Depending on the size and patient condition, the surgeon may choose to perform an endoscopic removal (Aybar & Safta, 2011). Most pediatric surgeons will perform open surgery and consider a conventional laparotomy to be their chosen practice (Middleton, Macksey, & Phillips, 2012).
Follow-up with mental health specialists is crucial in the treatment of a trichobezoar. Children with a trichobezoar frequently have some psychiatric conditions, mental deficits, or a history of neglect or abuse (Middleton et al., 2012). Postoperative consults to a psychiatrist should be considered by the surgical team. Most patients with trichotillomania and trichophagia will benefit from close follow-up from a psychiatric team to avoid reoccurrence (Matoq et al., 2017).
Acknowledgments
The authors thank Dr. Steven Megison and Dr. Diana Diesen.
References