TRICHOBEZOAR OF THE STOMACH AND DUODENUM : A CASE REPORT
Dr N. R. Pathak, Pathak Hospital, Miraj, India.
Bezoars are foreign bodies which increase in size by nature of their ability to take substance after being ingested along these are hair, vegetable fibers, etc. Bezoars of the hair balls (Trichobezoars) are the most common.
The earliest case was reported- Baudament in 1779. DeBakey and Oschner (1938-39) made exhaustive review as regards history, incidence and modes of formation and symptoms and diagnosis and complications of Bezoars. Hyatt, Burke and Hollenbeck reported the total world known number 230 after adding one of theirs. In India Nazareth (1956) Shrivastav et al (1958), Sayyed et al (1960) have reported one case each. Malhotra and Khanchand (1957) reported two cases, Jalandarwalla and Shah (1963), Khan et al (1962) reported one case each, some cases must have remained unreported. Of these cases reported by Trafford (1934) and Malhotra and Kanchand and Sayed et al were of intestinal obstruction caused by Trichobezoars.
Trichobezoars are formed as ingested hair accumulated over years are churned into clumps with epithelial elements, mucus and food material in the stomach or intestine. The lump takes the shape of the stomach and tends to extend into Duodenum. It appears dark green and is foul smelling due to fermented contents in the stomach.
Trichophagia is a personality disorder however, the Psycho-dynamics is not clearly known. Though Trichophagia may be from childhood, the cases are detected in the age group of 15 to 30 years in over 801 of cases more being in females. The early course of the disease is symptomless but when the mass almost fills the stomach symptoms appear. Anorexia vague abdominal pain nausea and vomiting and loss of weight are complained by the patient. Diagnosis is likely to be missed if history of Trichophagia over many years and occasional passing of hair with stools are not elicited because there are no specific diagnostic signs of this disease. –
Barium opaque meal X-ray gives a complex patchy screen like appearance due to the Barium in between the meshes in the interlacing hair
Case report:
A 20 year old Hindu boy attended the out-patient department of our hospital with complaints of 1) Nausea 2) vomiting after food, 3) Pain in abdomen and 4) weakness over more than two months
On examination he was a well-built boy except for lack of hair of the heard and very sparse moustaches. His voice was high pitched with a female tone. There was a large mass occupying the whole of the epigastrium. The mass extended from the left subcostal region to the right subcostal region and down to the umbilicus it could be moved up and down and from side to side and could be felt as a filled leather bag. History revealed occasional passage of hair; the patient detected this since he was 15 years old. Parents told that the boy had habit of trichotillomania and trichophagia since he was 2 years of age. The boy said he started eating more hair since 15th year of his age. He used to collect hair from the roadside near barber shops and used to chew them as hair balls and thence swallow. This gave him great pleasure as some get when chewing tobacco or beatle-nut.
Descending Pyelography revealed normal kidneys and ureters. X-ray after Barium Meal showed shadow of interlacing in the epigastric region.
His urine showed Albumin slight trace and W.B.C. + Stool report was normal. Blood report was Hb 84% R.B.C. 4,260,000/cmm W.B.C. 15,200/cmm DLC Segments 57% stab-3%, lymphocytes 36%, mono 2%, eosino 2%, baso nil. He was operated on 19th July, 1962.
OPERATION NOTES.
Incision was taken in the median line from Xiphisternum to the umbilicus. On opening the abdomen the anterior wall of the stomach came in view. The mass was found in the stomach and extended down to the second part of the duodenum. Finger could be indented over the stomach wall. A suitable site was chosen on the fundal side of the median line and towels were put and sutured over either side of the site of the incision. Incision was taken from lesser curvature to the greater curvature. On opening the stomach a dark greenish yellow glistening mass with foul smell was found extending from the fundal dome of the stomach near diaphragm down to the duodenum. Attempts made to remove the mass manually failed due to slippery surface and broad fundal part of the mass abutting the stomach wall. The fermented fluid in the stomach was removed with an electric sucker. A big toothed forceps was used to pull the mass but this resulted in dismantling hair of the matted anterior surface. Therefore, a myoma screw was put at the fundal end and gradually the fundal end was pulled out ironing the edges of the stomach wound as we do in helping delivery of a foetal head, the assistant supporting the stomach wall to avoid irregular tear. Once the fundal end was removed the mass came out easily including the duodenal end which was tapering and there was a gush of bile. This was aspirated. The fundal end was broadest with a beak like end near the cardiac opening. Thus the whole mass had taken the shape and size of the stomach pylorus and duodenum. Apparently it looked like a dead rodent. The actual measurement was 24.5″(63 cm) length and breadth 5”(12.75cm) and thickness 4”( 10.2 cm)
The colour was dark green glistening with mucus covering.
Mercurochrome was applied to the wound and the wound was closed as usual. The penicillin was instilled and the abdominal wall sutured layer by layer.
SUMMARY-
In the post operative period the boy developed hypostatic pneumonia, but responded to antibiotics and chemotherapy. Further recovery he was discharged on 30th July, 1962. Since then he attends clinic as a follow up case. He is enjoying good health and is helping his father in business.
A case of Trichobezoar occupying the whole cavity of stomach, pylorus and first two parts of the Duodenum in a young boy of 20 is presented. As there was no free space to remove the mass with hand or forceps and attempts of applying toothed instruments showed tendency of spilling of fermented materials and hair pieces, a myoma screw was used with satisfaction without disturbing the meshwork of the mass.
References:
l) B. A. Sayed et Sahagal, Kothari,Trichobezoar causing Acute Intestinal Obstruction. Ind.Journ.Surg. Vol.XXII. 488-90 1960.
2) M. A. Khan Ramchandran and Verma. Trichobezoar, Ind. Journ. Surg. Vol. XXV. 901-13. Dec 1962.
3) P.M. Julundharwala and S.W. Shah. Trichobezoar in the Jejunum. Ind. Journ. Surg. Vol. XXV. 463-68. 1963.
4) M. O. Canter and R. P. Reynolds. Gastrointestinal Obstruction. Baltimore. The Williams and Wilkins Co. 1957 p.63
5) Rodney Maingot. Abdominal Operations. London. H. K. Lewis & Co. 1961. P.62.
