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(Radiology. 2000;217:739-742.)
© RSNA, 2000

Diagnosis Please

Case 29: Gastric Trichobezoar and Subphrenic Abscess1

Benjamin Z. Koplewitz, MD, Alan Daneman, MB, BCh, FRACR, FRCPC, Scott Fields, MD, Raphael Udassin, MD and Sigmund H. Ein, MDCM, FRCSC, FACS, FAAP

1 From the Departments of Radiology (B.Z.K., S.F.) and Pediatric Surgery (R.U.), Hadassah Medical Center, PO Box 12000, Jerusalem 91120, Israel, and the Hebrew University, Jerusalem, Israel; and the Department of Diagnostic Imaging (B.Z.K., A.D.) and the Division of General Surgery (S.H.E.), the Hospital for Sick Children, Toronto, Ontario, Canada, and the University of Toronto. Received May 12, 1999; revision requested June 10; revision received June 30; accepted July 22. Address correspondence to B.Z.K. (e-mail: benk@md.huji.ac.il).

Index terms: Bezoar, 72.462 • Diagnosis Please • Gastrointestinal tract, perforation, 72.71 • Peritoneum, abscess, 7934.21 • Stomach, CT, 72.12112 • Stomach, diseases, 72.462


   HISTORY
TOP
 HISTORY
IMAGING FINDINGS
 DISCUSSION
 REFERENCES
 
A 14-year-old girl presented with low-grade fever and cough of 7 days duration, as well as pain in the left side of the chest, aggravated by deep inspiration, for 1 day. There was no history of trauma or previous surgery. Results from physical examination, basic laboratory studies, electrocardiography, and cardiac ultrasonography (US) were unremarkable. A chest radiograph was obtained (Fig 1). Her symptoms, attributed to a respiratory infection, resolved after treatment with analgesics, and she was discharged after 3 days. She was well until 10 days later, when she was readmitted because of cough, high fever, abdominal pain, and vomiting. Physical examination revealed dullness at percussion and decreased air entry in the base of the left lung. A 16-cm firm, nontender mass was palpated in the epigastrium. There were no signs of peritonitis. The rest of the physical examination results were unremarkable. Results of laboratory studies demonstrated anemia, with a hemoglobin level of 95 g/L (normal values, 120–140 g/L) and an elevated erythrocyte sedimentation rate of 80 mm/h (normal values, 10–20 mm/h). A chest radiograph (Fig 2) and computed tomographic (CT) scans (Fig 3) of the chest, abdomen, and pelvis were obtained.



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  		Figure 1. Posteroanterior chest radiograph obtained at the first admission. A curvilinear soft-tissue opacity (arrowheads) is delineated by air under the mildly elevated left hemidiaphragm. Note the presence of air-fluid levels (solid arrows) lateral to this soft-tissue opacity and the lobulated soft-tissue opacity (open arrows) inferomedially.

 


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  		Figure 2. Posteroanterior chest radiograph obtained at the second admission 2 weeks later shows left pleural effusion (curved arrow) and blurring of the left hemidiaphragm. Note the large left upper quadrant soft-tissue opacity (straight arrows) with an air-fluid level.

 


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  		Figure 3a. Selected transverse CT images of the upper abdomen obtained following oral and intravenous administration of contrast material at the second admission. (a) Large left subphrenic fluid collection with a rim of high attenuation (arrowheads) and an air-fluid level displaces the spleen (SP) posteriorly and the contrast material-filled compressed stomach (ST) medially. (b) Beak (arrow) of contrast material extends laterally from the greater curvature of the medially displaced stomach toward the collection, which illustrates the presumed perforation site.

 


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  		Figure 3b. Selected transverse CT images of the upper abdomen obtained following oral and intravenous administration of contrast material at the second admission. (a) Large left subphrenic fluid collection with a rim of high attenuation (arrowheads) and an air-fluid level displaces the spleen (SP) posteriorly and the contrast material-filled compressed stomach (ST) medially. (b) Beak (arrow) of contrast material extends laterally from the greater curvature of the medially displaced stomach toward the collection, which illustrates the presumed perforation site.

 

   IMAGING FINDINGS
TOP
 HISTORY
 IMAGING FINDINGS
DISCUSSION
 REFERENCES
 
A chest radiograph (Fig 1) obtained at the first admission demonstrated mild elevation of the left hemidiaphragm. A curvilinear soft-tissue opacity was seen inferomedial to the diaphragm, delineated by a radiolucent area of air superiorly, with air-fluid levels present laterally. An irregular, lobulated soft-tissue opacity was visible in the left upper quadrant. These radiographic findings were not appreciated at the time and were thought to be related to air in the splenic flexure. A chest radiograph (Fig 2) obtained at the second admission, 2 weeks later, demonstrated left pleural effusion and obscuration of the left hemidiaphragm. A round soft-tissue opacity with a large air-fluid level occupied the left upper quadrant.

CT at that time revealed a large left subphrenic fluid collection with an air-fluid level and a rim of high attenuation. The collection displaced the stomach medially and the spleen posteriorly (Fig 3a). An intraluminal mottled mass of low attenuation filled the stomach (Fig 3b) and extended to the duodenum and proximal jejunum (on additional images, not shown). The mass had a meshlike appearance with trapped bubbles of gas at the periphery and was delineated by orally administered contrast material circumferentially. A "beak" of contrast material projected laterally from the greater curvature of the stomach toward the subphrenic collection (Fig 3b).


   DISCUSSION
TOP
 HISTORY
 IMAGING FINDINGS
 DISCUSSION
REFERENCES
 
At the first admission, the girl appeared to have had a respiratory infection. At the second admission, her symptoms and the findings of a firm nontender epigastric mass, anemia, and elevated erythrocyte sedimentation rate raised suspicion of a malignant space-occupying lesion or a chronic infectious process. The CT findings led to the diagnosis of a subphrenic abscess, presumably due to a sealed-off gastric perforation secondary to compression and mucosal ulceration by the large bezoar in the stomach. There was no evidence of a pulmonary parenchymal process or bowel wall thickening, and no nodal masses were demonstrated in the chest or abdomen as evidence for lymphoma, gastric neoplasm, pneumonia, or tuberculosis. The pleural effusion and the basal lung changes were therefore thought to be reactive to the intraabdominal process.

US-guided aspiration yielded 700 mL of pus, and a drain was left in situ. In reply to specific questions, the girl admitted that she had been swallowing her hair for a long time; however, foci of alopecia were not found at physical examination. Endoscopy was used to confirm the presence of a large trichobezoar, but an attempt at removal was unsuccessful. The girl had an uneventful recovery following 12 days of intravenous antibiotic therapy. Three weeks later, a 900-g gastroduodenal trichobezoar (Fig 4) was removed by means of laparotomy and gastrotomy. At laparotomy, gastric mucosal irritation was noted; complete exploration of the abdominal cavity with mobilization of the stomach was deliberately avoided owing to the recently healed presumed perforation.



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  		Figure 4. Photograph shows a 900-g trichobezoar that was removed through a gastrotomy. Note the exact shape of the stomach, duodenal bulb, and duodenum.

 
Gastrointestinal trichobezoars can cause a spectrum of clinical findings that may vary according to the stage of trichobezoar formation, the length of the time it is present, and its position in the gastrointestinal tract. During the early stage, anorexia, malaise, vague abdominal pain, and headaches may occur; weakness and weight loss were noted in 38% of patients (1).

As the trichobezoar grows larger, recurrent bouts of nausea, vomiting, epigastric pain, and occasionally hematemesis can occur because of intermittent gastric outlet obstruction. The growing bezoar can cause compression and repeated mechanical irritation, leading to chronic inflammation of the gastric mucosa; Ménétrier disease, gastric polyposis, and protein-losing enteropathy with steatorrhea have been described (2,3). Iron deficiency anemia is a common laboratory finding, and may be a result of impaired gastrointestinal absorption, but was considered to be the cause for trichophagia, as a form of pica syndrome, with subsequent bezoar formation (4,5).

Intramural pneumatosis and emphysematous gastritis have been reported in association with gastric bezoars, presumably secondary to continuous mechanical compression and obstruction (6,7). The continuous compression can cause pressure necrosis with resultant mucosal erosions and ulcers, found most commonly along the lesser curvature, reported in 10% of patients with trichobezoars (1). This may subsequently lead to bleeding, perforation, and peritonitis (1,5,8–11); to our knowledge, subphrenic abscess formation, as occurred in this patient, has previously been described in humans in only one study in the English-language literature (8).

Extension of a gastric trichobezoar to the small bowel, as in this patient, is not an uncommon complication (1,5,12–14). Such an extension may compress the bowel wall and cause edema and secondary obstruction of the pancreatic duct or the common bile duct, with resultant pancreatitis or transient jaundice (15–17). Gastric trichobezoars have been reported to extend throughout the entire bowel (the Rapunzel syndrome) (12-14,18,19) and cause small-bowel intussusception (1,5, 20,21) or perforation (5,20,22–24). Occasionally, a piece of a gastric trichobezoar may break off and lodge in the distal small bowel (1,25), with resultant distal small-bowel obstruction. It is therefore mandatory that the entire bowel be thoroughly examined at laparotomy.

Imaging findings of gastric bezoars are characteristic; the diagnosis can often be made on the basis of findings at conventional radiography and barium study of the gastrointestinal tract. In this patient, the gastric mass was evident on the initial chest radiograph. The appearance of a gastric trichobezoar is of a mottled soft-tissue opacity in the shape of the distended stomach (5). A calcified rim may delineate the edge of the bezoar, which may extend to the small bowel (26).

An upper gastrointestinal series may outline a large filling defect in the stomach and duodenum and can extend to the proximal small bowel (8). Additional filling defects can be seen in the distal small bowel, presumably owing to breakage of the bezoar and lodging in the small bowel.

At US, a curvilinear bright echogenic band with posterior shadowing and no through transmission is demonstrated. This appearance is a result of the high echogenicity of the hair, as well as multiple acoustic interfaces created by food debris and air trapped within the highly compacted bezoar (27–31).

CT can demonstrate a large meshlike intraluminal mass of lower attenuation. The mass can contain trapped air or contrast material administered during a previous upper gastrointestinal series and may demonstrate concentric rings (14,31,32). When the intestinal lumen is not completely obstructed, orally administered contrast material can be used to delineate the outer surface of the mass. Manifestations of complications such as small-bowel obstruction or perforation, peritonitis, or abscess formation can also be documented.

The magnetic resonance appearance of gastric trichobezoar may vary according to its relative contents of air, fat, water, or residual retained food (33). It may demonstrate a gastric mass with low signal intensity on the T1-weighted, T2-weighted, and fat-suppressed T2-weighted images owing to the presence of air (11); increased signal intensity on the T1- and T2-weighted images because of water or food trapped within the bezoar; and foci of higher signal intensity on the T1-weighted and inversion-recovery images because of fat (33). Foci of inflammation due to gastritis or ulceration and perforation can also be detected (11).

Treatment of gastric trichobezoar is surgical. Endoscopic retrieval of gastric bezoars has been reported (34), but the large size of the trichobezoar makes this option impractical in most cases. Extracorporeal shock wave lithotripsy and endoscopy with the use of laser ignition with miniexplosions have been suggested as alternative approaches (35,36). Laparoscopic removal of a large gastric trichobezoar has recently been described (37).

Perforation and subphrenic abscess formation are uncommon complications of gastric trichobezoars. Although characteristic features at conventional radiography and barium studies can promptly disclose the diagnosis, cross-sectional imaging methods are useful for evaluation of such potential complications and when a broad differential diagnosis exists owing to an obscure clinical presentation.

Our congratulations to the 35 individuals who submitted the most likely diagnosis (gastric trichobezoar and subphrenic abscess) for Diagnosis Please, Case 29. Credit was given only if both bezoar and either subphrenic abscess or perforation were included in the most likely diagnosis. The names and locations of the individuals, as submitted, are as follows:

Miguel Blanco Ulla, MD, Santiago de Compostela, Spain
Frank Bonelli, MD, PhD, Rockford, Ill
Eric Bressler, Minnetonka, Minn
Christophe J. Chagnaud, MD, Marseille, France
Pablo Cikman, MD, Córdoba, Argentina
Burkhardt Danz, MD, Ulm, Germany
Francis Flaherty, MD, Ridgefield, Conn
Milton Fuentealba, MD, General Roca, Rio Negro, Argentina
Dietrich Gerhardt, Waterloo, Iowa
Alberto Iaia, MD, Wilmington, Del
Manoj Jain, MD, Chandigarh, India
Douglas S. Katz, MD, Mineola, NY
Mitchell A. Klein, MD, Milwaukee, Wis
Paul Madsen, MD, Greendale, Wis
Antonio Jose Madureira, MD, Porto, Portugal
N. B. S. Mani, MD, Chandigarh, India
Sergio J. Moguillansky, MD, Cipolletti, Rio Negro, Argentina
George M. Patramanis, MD, Coal Valley, Ill
R. Prashant, Ahmedabad, India
Dr. Pieter Pretorius, Oxford, England
Anita Price, MD, Mineola, NY
R. Rajesh, Ahmedabad, India
Enrique Remartinez Escobar, MD, Melilla, Spain
Matt Rheinboldt, Lafayette, La
Thomas Roeren, MD, PhD, Aarau, Switzerland
Pierre Jean Sauvage, MD, Mâcon, France
Domingo J. Schwarz, MD, Capital Federal, Buenos Aires, Argentina
Matt Shapiro, MD, Lowell, Mass
Thomas Solbach, Ulm, Germany
J. Takasugi, Mercer Island, Wash
Philippe Vanlede, MD, Izegem, Belgium
Angelo Vanzulli, MD, Milan, Italy
Christopher Vittore, MD, Rockford, Ill
Richard Whitehead, MD, Brookline, Mass
Joe Yut, Olathe, Kan


   FOOTNOTES
 
Part 1 of this case appears 4 months previously and may contain larger images.


   REFERENCES
TOP
 HISTORY
 IMAGING FINDINGS
 DISCUSSION
 REFERENCES
 

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