Large gastric trichobezoar causing failure to thrive and iron deficiency anaemia in an adolescent girl: a case report emphasising the imaging findings and review of the literature

Abstract

Failure to thrive, iron deficiency anaemia and abdominal pain are common paediatric presentations to general practitioners, outpatient clinics and are often referred to emergency departments. When young female patients suffering from psychiatric disorders, such as trichotillomania and trichophagia present to medical practitioners, the rare diagnosis of a trichobezoar, which is an accumulation of indigestible human hair in the gastrointestinal tract (90 % occurring in the stomach) needs to be suspected. Imaging is the mainstay of trichobezoar diagnosis and requires accurate interpretation to prevent complications. A case of a 14-year-old girl is presented, who was referred from paediatric outpatient clinics for an elective admission to the emergency department. She presented with abdominal pain, iron deficiency anaemia, failure to thrive and an epigastric/left upper quadrant mass felt on examination. A large trichobezoar was found on CT images, confirmed on endoscopy and removed with an open laparotomy. However, on the work-up imaging modalities, the radiologists missed the subtle findings of a trichobezoar. Although uncommon, trichobezoars should be considered as a differential diagnosis in female paediatric patients with a psychiatric history, who present with abdominal pain and epigastric mass. Imaging is the mainstay for trichobezoar diagnosis. As such, radiologists need to be familiar with the apparent, and subtler, pathological findings of this diagnosis and possible differential diagnoses across all imaging modalities. After successful treatment, psychiatric consultation and treatment is imperative in order to prevent reoccurrence.

Figure 1.

Abdominal ultrasound on 1 February 2018: demonstrating an echogenic curved band (green arrows) with posterior acoustic shadowing (blue arrows) in the left upper quadrant of the abdomen. LUQ, left upper quadrant.

Figure 2.

CXR on1 February 2018: demonstrating the upper portion of the large bezoar projecting into the gastric air bubble (blue arrow), with no signs of pneumoperitoneum or other complications.

Figure 3.

Contrast enhanced axial and coronal CT C/A/P on 1 February 2018: demonstrating a huge oval, heterogeneous, well defined, solid appearing, non-enhancing intraluminal mass, measuring 13 × 6 × 6 cm, in a distended stomach (blue arrows). With no extension of the large mass through the pyloric canal.