British Spas and Health Resorts
Authors: A. P. Cawadias
Journal: BMJ (1950)

<h3>Aims</h3> To describe a case of an 11 years old girl with complicated intestinal obstruction caused by trichobezoar. <h3>Methods</h3> We report a case of Trichobezoar presenting with severe chronic abdominal pain and intestinal obstruction leading to toxic megacolon. We describe the management of this case and include the radiological image and surgical samples pictures. (figure 1A and figure 1B ). The patient is an 11-year-old female, with an unremarkable medical history, who presented with 2 months history of persistent central abdominal pain and episodes of severe short-lasting exacerbation. In addition, she had significantly decreased appetite, weight loss, and progressively worsening constipation. On examination, she was cachectic, pale, with palpable soft ill-defined mass in the left lower abdomen. Multiple ultrasound abdomen studies showed intermittent intussusception; however, MRI was concerning for malignancy as it showed Multiple segments of significant wall thickening involving the small bowels with subacute/incomplete bowel obstruction findings. For this reason, abdominal lymph nodes were taken for biopsy to rule out small bowel lymphoma. The pathological report was inconclusive. At that time, the patient was experiencing severe continuous abdominal pain for which morphine was given. The patient became sicker and was not tolerating any oral intake. The abdominal X-ray at this point showed toxic megacolon (figure 1A). Urgent surgical laparotomy was done, and findings were intussusception involving a large segment of small bowel from and string (bezoar) going from the duodenojejunal junction down to the ascending colon. the entire small bowel was intussuscepted over the short thread of hair that measures approximately 30 cm. this tight string of hair caused a shearing effect cutting through the bowel wall causing fistulation between multiple bowel segments. multiple non-viable segments of the small bowel were resected. the stomach was visualized with scope, which showed trichobezoar resected surgically (figure 1B). <h3>Results</h3> Trichobezoar is a collection of hair in the gastrointestinal tract, usually, the stomach, caused by chronic hair pulling and ingestion. This condition is called trichotillomania, a mental disorder that typically strikes during adolescence and has a chronic course. Patients who suffer from trichotillomania usually have patchy hair loss, a sign that was absent in our patients. In addition, the patient in our case presented with symptoms that resemble other conditions like intestinal lymphoma and inflammatory bowel disease. Radiological imaging can be diagnostic in 97% of the case; however, in other cases, further investigations and surgical exploration might be warranted. The clinical course in our case was severe indicating the devastating effect trichobezoar can lead to. <h3>Conclusion</h3> Diagnosis of intestinal obstruction due to trichobezoar may not be straightforward especially in patients who have not been diagnosed with mental diseases or lack the clues on physical examination. Although it is an uncommon cause of intestinal obstruction, it should be included in the differential diagnosis when possible.