Ileal Trichobezoar Causing Small Intestinal Obstruction: A Rare Variant

MED PHOENIX: An Official Journal of NMC, Birgunj, Nepal Volume (5), Issue (1), July 2020, 82-85 ABSTRACT Bezoars are conglomerate mass of ingested foreign material commonly found in stomach and small intestine in patients with psychiatric problems. On the basis of composition bezoars are classified into many variants. Trichobezoar and phytobezoar are most common composed of hair and fibers of fruits and vegetables, respectively. Bezoar itself is a rare entity and the bezoar solely present in small intestine causing intestinal obstruction is rarer, so we present a case report of 7 years old girl presented in our emergency with the feature of intestinal obstruction. Diagnosis was made on the basis of clinical examination, x-ray finding and history of trichophagia. On exploratory laparotomy the cause of obstruction was found to be ileal trichobezoar.


INTRODUCTION
Bezoars are conglomerate mass of ingested foreign material. The word bezoar is derived from the Arabic word Badzehr or Bazahr meaning antidote which was used until 18 th century for management of plague, snakebite, leprosy, epilepsy by physicians of that era. 1 Bezoars are classified on the basis of compositions such as trichobezoar (hair), phytobezoar (vegetable fibres), lactobezoar (milk products), pharmacobezoar (drugs). Trichobezoars is composed of patient's own hair and is rare in children. Hair pulling or trichotillomania is the abnormal desire to pull out one's own hair and ingesting it is called as trichophagia. The condition is usually associated with the mentally retarded or with young children and may be caused by a variety of psychiatric conditions. Stomach is a common site for formation of bezoars which can migrate into the small bowel loops and when remain undiagnosed can lead to complications such as ulcers, gastric bleeding or perforation and obstruction. 2,3,4 Though a rarity, watchfulness is to be exhibited while managing patients, especially children with acute intestinal obstruction. Isolated presentation of ileal bezoar in absence of a parent bezoar in the stomach and without history of gastric surgery or underlying pathology is rare. Thus, in this case patient was diagnosed as a case of intestinal obstruction on the basis of clinical finding and x-ray but the cause was suspected on the behavior of trichotillomania and trichophagia.

Case presentation
A 7 years-old girl presented to our emergency department with the chief complaints of abdominal pain, distension, vomiting and absolute obstipation for 3 days. Her parents state that she has the habit of hair plucking and putting it into her mouth for a long time.
On clinical examination the patient was ill looking, emaciated, anemic with bilateral pedal edema. Her hair over the scalp was patchy of unequal length. Abdomen was distended, tense with exaggerated bowel sounds, visible peristalsis was seen and gut loops. Digital rectal examination shows empty rectum and collapsed. X-Ray abdomen erect view shows multiple air fluid level in small intestine and supine view shows level of obstruction to be distal ileum.
Blood investigation revealed Hb to be 8 gm/ dl and TLC 12,000/mm3, serum albumin 2gm/ dl. Rest of the routine blood investigations were within normal limits.
Management: Patient was resuscitated with IV fluids, nasogastric decompression and Foleys catheterization was done. Blood was transfused preoperatively and shifted to operation theatre for exploratory laparotomy. Transverse infraumbilical incision was given and peritoneum opened. On exploration there were 2 trichobezoars. One about 1.5 ft from ileocecal junction and other at 1 ft from ileocecal junction. It was the second trichobezoar causing obstruction. Proximal gut loops were dilated and distal collapsed. Rest of the gut was normal. Enterotomy was done and trichobezoar removed. Primary repair of Enterotomy was done in 2 layers, 1st extra mucosal interrupted and 2nd seromuscular interrupted. Drain was placed in pelvis. Post operatively patient was given albumin, blood and TPN along with antibiotics and analgesics. Patient developed SSI on 5th day with burst abdomen, retention sutures were applied. Psychiatric consultation was done for the patient and discharged on 12th day.

DISCUSSION
The case Trichobezoars, itself is a rare case in surgical practice. It is usually associated with underlying psychiatric disorders such as depression, obsessive-compulsive disorders, body dysmorphic disorder and particularly, trichotillomania. 5,6,7 Depending on the case series, 5 to 30% of the patients with trichotillomania engage in trichophagia, 8,9 while 1 to 37.5% of these will develop a trichobezoar. 5,7,10,11 As Bouwer and Stein point out, it is also striking that trichophagia was described a century before trichotillomania, while an early case series of trichobezoars remains larger than most case series of trichotillomania patients. 5,12,13,14 Most trichotillomania patients are referred to psychiatry units by their own initiative, while trichobezoar patients are usually referred in a late stage in surgery units. On other hand these patients may not be identified by clinicians as having a psychiatric problem, or they may simply be lost in psychiatric referral before landing in surgery with complications.
This was the case of the patient whose parents noticed the behavior of trichotillomania and trichophagia but due to illiteracy and ignorance did not consult with any doctors. The early detection of trichophagia and trichobezoar depends on an effective screening for trichotillomania and related behaviors, in order to prevent a possibly lifethreatening medical and surgical morbidity. Such effort must include a better collaboration between medical and surgical specialties, dealing with particular aspects of therapeutic relationship regarding shame and guilt as well as considering that trichophagia may be more often present than the majority of clinicians, psychiatrists in particular, would expect.
Recurrence of bezoars may occur mainly in emotional and behavioral disordered patients, therefore alongside removal of the bezoars the mental treatment and psychological support are also considered to avoid the relapse. Therefore, we reported the case of trichobezoar, suffering from trichophagia, who presented lately, we managed the case and psychiatric counseling was given.