Purpose or Case Report: A 10-year-old girl presented with 18-hour history of crampy periumbilical pain, associated with three episodes of non-bilious vomiting and anorexia over the past few days. She denied fever and had a normal bowel movement one day before admission. She had no medical history and was not on any medication. Her social development and school performance were both unremarkable. On physical examination, the abdomen was distended, tender in the periumbilical area, with normal bowel sounds and no peritoneal signs.
The abdominal radiograph showed air-fluid levels with distended small bowel loops and a large heterogeneous mass conforming to the shape of the stomach and a possible distended loop with mottled gas pattern in the mid pelvis, to the left of the midline. Six hours later, while in the hospital, the patient developed bilious vomiting and a computed tomography (CT) showed a mottled air-containing large mass within the stomach and a second smaller similar appearing mass within a segment of small bowel in the left lower quadrant, with diffuse distension of small bowel loops and multiple air-fluid levels proximal to it, in keeping with small bowel obstruction (SBO). The patient admitted to trichotillomania and trichophagia and a patch of alopecia was noted in the left parietal scalp. She was sent to the operating room where a supraumbilical vertical midline incision was made and a large obstructing trichobezoar completely filling the gastric lumen was removed through a transverse gastrotomy. The small bowel was inspected and a palpable, obstructing smaller trichobezoar was removed from the jejunum, approximately 1 meter from the pylorus.
Trichobezoars form after the ingestion of large amounts of hair, often over many years. Although trichotillomania affects about 1% of the population, only one third have trichophagia and just 1% of these individuals eat enough hair to require surgical intervention, making trichobezoars very uncommon in clinical practice. They are usually single and seen in the stomach, but in 5% of cases more then one bezoar is found. SBO occurs in fewer than 10% of patients with trichobezoar.
Plain radiographs are usually the initial imaging tool for diagnosis of SBO. CT can be helpful in determining the presence of obstruction in clinically suspected cases with equivocal plain radiographs, and determining the site and cause of obstruction, including trichobezoars.
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