Castro Denise,  Silva Cecília,  Paranhos Isabela,  Lira Andréa,  Fonseca Josélia,  Ribeiro Rafaela

Final Pr. ID: Poster #: CR-045

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. Read More

Authors:  Castro Denise , Silva Cecília , Paranhos Isabela , Lira Andréa , Fonseca Josélia , Ribeiro Rafaela

Keywords:  trichobezoar, small bowel obstruction, simultaneous, synchronous, bezoar

Pryor William,  Fordham Lynn,  Smith Ben,  Tulchinsky Mark,  Donnelly Lane,  Guimaraes Carolina

Final Pr. ID: Poster #: EDU-040

Gastric bezoars are mobile masses of indigestible material within the stomach that result from the ingestion of various substances, including hair (trichobezoar), indigestible plants/vegetables (phytobezoar), indigestible drugs (pharmacobezoar), or milk curd (lactobezoar). The most commonly encountered bezoars are trichobezoars, classically seen in adolescent females with trichotillomania. Patients with bezoars may present with nonspecific abdominal symptoms, including small bowel obstruction. The history of the ingested substance may not be readily apparent - due to development delay, physiological disorders, or young age. Trichobezoars may be encountered on multiple imaging modalities, because of the nonspecific abdominal symptoms and lack of specific history. While a high index of suspicion is necessary to diagnose bezoar on imaging, several classic signs may help pediatric radiologists make the correct diagnosis. In this educational exhibit, we present several examples of bezoars across the imaging spectrum – including radiography, upper GI, CT, ultrasound, & nuclear medicine gastric emptying studies. Associated complications and current treatment algorithms are also reviewed. Read More

Authors:  Pryor William , Fordham Lynn , Smith Ben , Tulchinsky Mark , Donnelly Lane , Guimaraes Carolina

Keywords:  Bezoar, trichobezoar, trichotillomania

Dawani Anuradha,  Jagani Sumit

Final Pr. ID: Poster #: CR-018

Bezoars are an uncommon cause of small bowel obstruction (SBO) in children. Trichobezoars are typically seen in adolescent girls who swallow their hair. Lactobezoars are another unusual cause of intestinal obstruction in neonates/infants. Phytobezoars, foreign body bezoars and pharmacobezoars are other types of bezoars. CT is a useful tool in diagnosing the cause of SBO, however, SBO caused by bezoars may not be detected on a CT exam as it presents as faeces like material proximal to the transition point. Ultrasound (US) can help differentiate a bezoar from faeces. The diagnostic signs of a bezoar on US include an echogenic, arc-like surfaced intraluminal mass, strong posterior acoustic shadowing and twinkling artefacts from the front of the mass resulting from the rough hard surface and high acoustic impedance differences within the internal structure of a bezoar. These features are not seen with faecal material.

We present two cases of bezoar induced SBO. The first case was a small intestinal trichobezoar in an 11 year old female child who presented with abdominal pain and bilious vomiting since 4 days. US demonstrated dilated small bowel with classic appearances of a bezoar in distal ileum. CT was not done in this instance and patient underwent surgery based on US findings. Same patient was also shown to have a large gastric bezoar on further endoscopic and ultrasound evaluation. Second case was a lactobezoar in a 9 month old infant that presented with copious bilious aspirates in NG tube, post difficult hernia reduction. CT demonstrated acute SBO with transition point at IC junction and faeces like intraluminal material proximal to it. US again showed characteristic appearances of a bezoar thus clinching the diagnosis. First patient underwent extraction via enterotomy and the second patient was treated with fragmentation and milking out.

Our cases highlight following learning points: 1. US shows characteristic appearances and improves diagnostic accuracy in conjunction with CT thus helping radiologists to quickly and easily diagnose bezoar. US can also suffice as first line and only imaging investigation needed. 2. Lactobezoar should be kept as a differential for SBO in neonates/infants. 3. In cases of intestinal bezoars, possibility of further proximal/gastric bezoars must be explored. Read More

Authors:  Dawani Anuradha , Jagani Sumit

Keywords:  Abdominal Ultrasound, Bezoar, Diagnostic Accuracy