Pre-Screening: Case Report: Trichobezoar Causing Small Bowel Obstruction

Posted By Rav Dhatt
Pre-Screening: Case Report: Trichobezoar Causing Small Bowel Obstruction

Dear JRCR editor(s): We hope you will consider the following case as suitable for submission to the JRCR: Our patient was a 6-year-old previously healthy, immunized and developmentally normal female. She presented with a one-day history of 5-6 episodes of bilious emesis, periumbilical pain and intolerance to fluids or solids. The emergency room physician was particularly struck by how foul the emesis smelled and how unusual it looked. She had 2 isolated incidents of nonbilious emesis in the past 3 weeks. The patient had no bowel movements for 2 days but was passing flatus. Patient did have a history of constipation. There was no family history of inflammatory bowel disease or celiac disease but her mother did have a history of irritable bowel syndrome. On physical examination, the patient was afebrile and demonstrated periumbilical tenderness. Bowel sounds were present and her abdomen was nondistended. Laboratory investigations revealed a mild leuokocytosis but otherwise inflammatory markers were normal. The patient was admitted into hospital, during which she had intermittent bilious vomiting. The general pediatrics, gastroenterology, general surgery and radiology services were involved in the care of this patient. Imaging Findings: While admitted numerous investigations (Abdominal x-ray, upper GI and small bowel series, abdominal ultrasound, upper GI endoscopy, CT abdomen) were ordered to determine the etiology of her symptoms. On Day 1 of admission, the initial abdominal radiograph was normal and showed no signs of obstruction (Figure 1). An upper GI series followed, which demonstrated slow transit with contrast being held up in a dilated jejunal loops with mild mural thickening (Figure 2). On Day 2, ultrasound examination demonstrated mildly dilated, fluid-filled proximal bowel loop with mild wall thickening and no free fluid (Figure 3). The pediatric gastroenterology service was consulted at this point and an upper endoscopy was performed which was found to be normal. Radiograph performed on Day 3 following the upper endoscopy demonstrated a barium-coated mass in the left upper quadrant and a few dilated proximal small bowel loops (Figure 4). On the subsequent radiograph on Day 5, the barium coated (from upper GI series) intraluminal mass was noted to have moved from the left upper quadrant to the right lower quadrant and multiple central air fluid levels were present suggestive of bowel obstruction (Figure 5). No evidence of pneumatosis or pneumoperitoneum was seen on plain radiographs. On Day 6 of admission, a contrast enhanced computed tomography (CE-CT) of the abdomen and pelvis was completed, without oral contrast as per normal protocols in our facility. This demonstrated a barium-coated (from upper GI study contrast) mass with a heterogeneous internal density in the distal jejunum/proximal ileum with no central contrast enhancement (Figure 6). There was a barium-coated “tail” extending distally from the mass (Figure 7). No gas

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  • Rav Dhatt 2017-11-01 20:30:34

    Hi Dr. Talanow,

    In most reported case reports, trichobezoars have been diagnosed with a combination of CT and upper endoscopy. Because of the age of our patient and perplexing clinical history, numerous modalities were utilized to minimize radiation exposure but determine the etiology of the patient’s symptoms. We are able to showcase and describe the progression of findings with various modalities that are not typically used for the diagnosis of this entity, such as ultrasound and upper GI series. I believe this progression of findings with a multimodality approach makes this case unique. Additionally, the slow transit of barium led to some unique radiographic and CT findings, which can provide insight for clinicians in similar challenging clinical encounters.

    Furthermore, our case is unique in that it was an isolated jejunal bezoar, which is far more rare than the more typical presentation of a duodenal bezoar or Rapunzel syndrome with an associated gastric bezoar.

    Although not described in the description above, we have described the various management options of trichobezoars including surgery, upper endoscopy and laser ignited mini-explosive technique in our discussion.

    I hope it will be considered for submission.



  • Roland Talanow 2017-10-15 19:23:46

    Thank you for these nice case illustration with several modalities. If interested in publication in the JRCR, could you please explain what makes this case case report worthy? There are over 2000 publications in Pubmed about trichobezoar and it is a known entity to cause SBO. Thank you!