A huge abdominal mass revealing a depressive syndrome

Abstract

Trichobezoar is a rare condition that occurs mostly in young women with psychiatric disorders such as trichotillomania and trichophagia. We report the case of a giant gastric trichobezoar in a 21-year-old woman who presented with chronic abdominal pain, vomiting and weight loss. Abdominal examination revealed a large epigastric mass. Endoscopic and imaging findings were highly suggestive of a gastric trichobezoar. Surgical extraction of the huge hair mass was successfully performed through an open gastrotomy. Postoperatively, history of a neglected chronic depression with suicidal ideation was diagnosed. Consequently, the patient was referred to the psychiatric department for mental healthcare, to prevent trichobezoar recurrences.

Background

Bezoars are solid masses of indigestible material that accumulate in the gastrointestinal tract. This term is derived from the Arabic word Badzehr or the Persian padzhar for antidote.¹ On the basis of their contents, bezoars can be classified into six types: phytobezoars (caused by plant material), trichobezoars (composed of hair), lithobezoars (accumulation of stones), pharmacobezoars (composed of medications), plasticobezoars (masses formed by plastic material), and lactobezoars (caused by inspissated milk).¹ Trichobezoars are caused by the accumulation of ingested hair in the gastric cavity and occasionally in the intestinal lumen. They are mainly seen in young women and are often associated with psychiatric disorders such as trichotillomania and trichophagia. Clinical presentation of trichobezoars is variable and non-specific, ranging from simple abdominal pain to serious complications including intestinal occlusion and perforation. The present report describes a giant trichobezoar in a 21-year-old woman and highlights important features of diagnosis and treatment options.

Case history

A 21-year-old woman with no prior medical history was admitted for non-specific epigastric pain accompanied by episodic non-bilious vomiting, asthenia and weight loss experienced over several months. There were no signs of transit disorders or digestive bleeding. On physical examination, a large firm mass was palpable in the epigastrium, extending toward the right upper quadrant. The mass was mobile, smoothly contoured and not fixed to the abdominal wall. The abdomen was flat and soft with normal bowel sounds. No peritoneal signs or overlying skin changes were found, except that the palpebral conjunctiva appeared pale.

Abdominal computed tomography clearly showed a distended stomach containing a large heterogeneous mesh-like mass with multiple air bubbles trapped and dispersed within the gastric cavity. This huge mass, measuring 32 × 18 × 10cm extended from the fundus to the pylorus, resulted in a compression of the surrounding structures. Initially hypodense, it was not enhanced on contrast. Any significant thickening of the gastric wall or signs of necrosis were noted (Figure 1). An upper gastrointestinal endoscopy identified a giant trichobezoar occupying the entire gastric cavity and part of the duodenum (Figure 2).

Figure 1 .

Computed tomography findings: (a) Axial view showing a giant heterogeneous mass into the gastric lumen containing trapped air. (b) Coronal view revealing that the mass induced gastric distension without parietal thickening and extend from the fundus to the pyloric canal.

Figure 2 .

Endoscopic findings: confirming the presence of a giant hairball in the gastric cavity

Laboratory tests revealed hypochromic microcytic anaemia with haemoglobin 105g/l and slight hypoalbuminaemia at 30g/l. Electrolytes, renal and liver function tests, amylase and lipase were within the normal range.

A laparotomy was decided because all attempts to extract the solid hairball by endoscopy failed. Under general anaesthesia, upper midline incision was done revealing a distended stomach with hard content but without any parietal lesion. The large hairball was extracted through a longitudinal gastrotomy performed along the anterior gastric wall (Figure 3). The mass was occupying the entire gastric cavity with a tail extending up to the proximal portion of the duodenum (Figure 4).

Figure 3 .

Operative view with a longitudinal gastrostomy

Figure 4 .

Appearance of the hair mass after surgical extraction

In the postoperative course, the patient reported an irresistible urge to pull out her hair and swallow it during the past three years. A neglected chronic depression with suicidal ideation was also discovered during her period of hospitalisation. The patient was discharged three days after surgery without any postoperative complication and referred to the psychiatric department for additional care and a long-term follow-up.

Discussion

Trichobezoar is a rare clinical entity that occurs predominately in young women under 30 years of age.² It is usually seen in patients with underlying psychiatric disorders such as trichotillomania and trichophagia. Trichotillomania is an obsessive-compulsive disorder characterised by repetitive, irresistible habit to pull hair resulting in a noticeable hair loss and significant distress. It can lead to trichophagia when the patient ingests one’s hair despite repeated attempts to control this compulsive behaviour.³ These conditions are usually present with other mental disorders, such as depression, anxiety, and social phobia.¹

Human hair is resistant to digestion as well as peristalsis due to its smooth surface, leading to its accumulation between the mucosal folds of the stomach. Over a period, continuous ingestion of hair leads to its impaction with mucus and food, causing the formation of a trichobezoar.⁴ In most cases, the hair mass is confined within the gastric lumen, but it can extend up to the jejunum or beyond. This rare form with a long tail was first reported by Vaughan et al in 1968 and was named Rapunzel syndrome.⁵ In this case, the post-pyloric extension of the trichobezoar tail distally into the small intestine may lead to serious complications including intestinal obstruction and perforation.⁴

Patients with gastric trichobezoars are usually asymptomatic, which can result in a diagnostic delay of many years. Clinical presentation in symptomatic patients is variable and non-specific. Most common signs include abdominal pain, nausea and vomiting, weight loss, anorexia and anaemia. As the mass increases progressively in size, it can lead to harmful complications such as intestinal obstruction, perforation, bleeding, cholestatic jaundice and acute pancreatitis.² At this stage, an abdominal mass is easily palpable on clinical examination. Additionally, a history of hair-eating is highly suggestive of trichobezoar, especially in patient with obvious patchy alopecia and severe halitosis.

Computed tomography is the most effective imaging study used to detect the presence of trichobezoars, as it reveals heterogeneous masses containing trapped air,¹ although endoscopy is considered to be the gold standard of diagnostic modalities with both diagnostic and therapeutic possibilities. Ultrasound and upper gastrointestinal series may also be useful.

Therapeutic management of trichobezoars depends on their size and the presence of complications. Endoscopic extraction can be attempted in small and proximal trichobezoars, but it is successful in only 5% of patients.⁴ Laparoscopic removal is also an attractive approach, but it seems to be technically very difficult with a prolonged operative time. Laparotomy is therefore still considered the technique of choice, especially in large and complicated forms.¹

A PubMed literature review was conducted for published articles about trichobezoars in adult patients aged over 19 years; 22 cases of gastric trichobezoar have been reported during the past five years (Table 1). In these patients, open surgery was the most common procedure. Often attempted, endoscopic removal was effective in only two patients with relatively small sized trichobezoars. Recently, Kurosu et al reported a case of a large trichobezoar extracted by laparoscopic and endoscopic cooperative surgery. This innovative procedure is therefore considered to be a useful treatment for giant gastric bezoars and is likely to become a treatment option in the future.

Table 1 .

Published case reports of gastric bezoar in adult women (>19 years) during the last 5 years

Year	Age (years)	Removal technique	Medical history	Authors	References
2020	24	Laparotomy and gastrotomy	Trichophagia	Zenaidi et al	Rev Med Interne 2020; S0248–8663(20)30196-X.
2020	20	Laparotomy and gastrotomy	Trichophagia	Lisi et al	Clin Gastroenterol Hepatol 2020; S1542–3565(20)30819–3. DOI: https://doi.org/10.1016/j.cgh.2020.06.015.
2020	23	Laparotomy and gastrotomy	Trichophagia, depression	Jain et al	J Family Med Prim Care 2020; 9: 2566–2568.
2019	48	Laparotomy and gastrotomy	Trichophagia	Mohammed et al	Int J Surg Case Rep 2019; 57: 33–35.
2019	43	Laparotomy and gastrotomy	Trichophagia	Mandujano Bejarano et al	Gastroenterology 2019; 157: e1–e2.
2018	25	Laparotomy and gastrotomy	Trichophagia, onychophagia	Shahab et al	Cureus 2018; 10: e3039.
2018	27	Laparotomy and gastrotomy	Trichophagia denial	Plaskett et al.	S Afr Med J 2018; 108: 559–562.
2018	23	Laparotomy and gastrotomy	Trichophagia, episodic stress	Plaskett et al	S Afr Med J 2018; 108: 559–562.
2018	21	Laparotomy and gastrotomy	Schizophrenia	Mazine et al	Pan Afr Med J 2018; 30: 25.
2018	21	Laparotomy and gastrotomy	Hyperactivity and attention disorders	Latorre Díez et al	Med Clin (Barc) 2018; 150: e33.
2018	32	LECS	Trichophagia, schizophrenia	Kurosu et al	Endosc Int Open 2018; 6: E1413–E1416.
2018	21	Laparotomy and gastrotomy	Trichophagia	Imran et al	J Coll Physicians Surg Pak 2018; 28: 63–65.
2017	36	Laparotomy and gastrotomy	Trichophagia	O’Flynn et al	Acta Gastroenterol Belg 2017; 80: 81–82.
2017	25	Laparotomy and gastrotomy	Trichophagia	Obinwa et al	World J Clin Cases 2017; 5: 50–55.
2017	23	Laparotomy and gastrotomy	Trichophagia	Jirapinyo et al	Gastroenterology 2017;152: 1843–1844.
2017	21	Endoscopy	Bipolar disorders	Gremida et al	Dig Dis Sci 2017; 62: 3321–3324.
2017	37	Endoscopy	Trichophagia, gastric bypass surgery	Amjad et al	BMJ Case Rep 2017; 2017: bcr2017220923.
2016	46	Laparotomy and gastrotomy	Trichophagia, psychosis	Tamini et al	Dig Liver Dis 2016; 48: 452.
2016	21	Laparotomy and gastrotomy	Clear medical history	Paparoupa et al	Mayo Clin Proc 2016; 91: 275–276.
2016	23	Laparotomy and gastrotomy	Habit of eating blanket string	Kumar et al	Med J Armed Forces India 2016; 72: 406–407.
2016	20	Laparotomy and gastrotomy	Adjustment disorders	Dixit et al	J Clin Diagn Res 2016; 10: PD10–PD11.
2016	30	Laparotomy and gastrotomy	Trichophagia	Ahmad et al	Iran J Med Sci 2016; 41: 67–70.

LECS, laparoscopic and endoscopic cooperative surgery

Finally, a multidisciplinary approach including a long-term psychiatric follow-up, behavioural therapy and dietetic education is essential to prevent trichobezoar recurrences in patients with psychiatric disorders.

Conclusion

Trichobezoar is an uncommon but serious surgical condition that requires a high level of suspicion. It should be considered in young women with non-specific abdominal symptoms, especially in the presence of a palpable abdominal mass. Diagnosis is easy with endoscopic and imaging studies. Surgical extraction continues to be the mainstay treatment option. However, underlying mental disorders are often associated with the clinical picture. In this case, a long-term psychiatric follow-up was necessary to prevent bezoar recurrences.