Washington Radiology Associates

The following case highlights the classic manifestations of a rare but significant clinical entity, trichobezoar. A 14-year-old female with no past medical history presented to an outpatient pediatric clinic with epigastric abdominal pain. The physical examination was notable for a midline abdominal mass. The patient was referred for a right upper quadrant ultrasound with concern for hepatomegaly. This showed a hyperechoic curvilinear midline structure with marked posterior shadowing, suggestive of a calcified mass. Given the location, a prominent xyphoid process was also considered, therefore, chest and abdominal radiographs were performed. No calcified mass was identified, however, an air-level on the upright view and a bubbly appearance of the left upper quadrant on supine view was seen, notable given that the patient was NPO. CT abdomen/pelvis was obtained showing a 14 cm mottled intraluminal mass extending from the gastric body to the fundus, with oral contrast surrounding the concretion. The mottled appearance was reflective of trapped air within this mass. Given the patient's age, physical exam, and imaging findings, the patient was referred to general surgery for removal of a suspected gastric bezoar. Intraoperatively, the mass extended into the distal esophagus and proximal duodenum and on gross and pathologic examination was determined to be a trichobezoar. Surgical removal was successful and the patient was referred to psychiatry thereafter. Our case illustrates a common presentation of an uncommon medical phenomenon, trichobezoar. This most often occurs in adolescent females with underlying psychiatric conditions who masticate and consume their own hair. Presentation is oftentimes confounded by a lack of forthcoming history from the patient, making early diagnosis difficult. Given its association with psychiatric disorders, it is imperative for clinicians to undertake a multidisciplinary approach to these patients. Unlike other subtypes of bezoars, surgical removal is preferred over endoscopic removal or chemical dissolution, as was performed in our patient. Trichobezoars can have life-threatening complications including gastric outlet obstruction, perforation, or intussusception, so clinicians must be aware of risk factors and subtle clinical findings in order to obtain an accurate diagnosis.Figure: CT Abdomen/Pelvis.Figure: Right Upper Quadrant Ultrasound.Figure: Chest and Abdominal Radiograph.

The purpose of this study is to examine the incidence of low-pressure syndrome in patients with pseudotumor cerebri and identify correlations between lumbar puncture techniques and subsequent low-pressure syndrome. A better understanding of what variables increase a patient’s chances of contracting low-pressure syndrome will help clinicians make more informed decisions about lumbar punctures.