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Within Normal Limits

A Surprising Abdominal Mass

Huynh, Tuan MD; Patel, Himanshu MD; Patel, Shivani MD

doi: 10.1097/01.EEM.0000473178.08098.49
Within Normal Limits

Dr. Huynhis a fifth-year radiology resident at Westchester Medical Center in Valhalla, NY, whereDr. Himanshu Patelis the director of musculoskeletal radiology. He is also an assistant professor of radiology at New York Medical College. Dr. Shivani Patelis an emergency physician at Stamford (CT) Hospital.

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A 14-year-old girl with no significant past medical history presented with complaints of vague abdominal pain and a palpable abdominal mass. She vomited twice in the 48 hours before presenting, and she reported progressive decreased oral intake over the past several months.

Consider the images and text below them to determine your diagnosis before reading on.

This girl has a trichobezoar. Bezoars are retained concretions of ingested material, the two most common types being trichobezoars and phytobezoars, which represent undigested hair and plant material, respectively. They can be difficult to diagnose clinically because of nonspecific clinical symptoms, which include abdominal pain, nausea and vomiting, weight loss, and early satiety.

Bezoars are most often found in the stomach but may extend into and obstruct the proximal small bowel, form primarily in the stomach and then “embolize” to distal small bowel, or form primarily in the small bowel. Trichobezoars are classically found in adolescent girls, often times with a psychiatric comorbidity, like trichotillomania. Other predisposing factors include a history of prior gastrointestinal surgery or gastroparesis.

Without a leading history, the diagnosis of bezoar is often delayed. Very large palpable bezoars can be misinterpreted as solid masses leading to workup for suspected malignancy. (Am J Roentgenol 2001;177[1]:65.) Small, nonobstructing bezoars are usually managed conservatively, and larger bezoars usually require laparotomy, laparoscopy, or endoscopy. Delayed complications of bezoar include gastric or small bowel perforation.

Start with routine abdominal x-rays if trichobezoar is suspected clinically; they are most useful in evaluating for intestinal obstruction because bezoar has a nonspecific radiographic appearance with a reported sensitivity of 18 percent in one small case series. (Pediatr Surg Int 2010;26[5]:457.) Additional imaging evaluation is usually warranted, most often with ultrasound and CT. Sonographic characteristics of bezoars include intraluminal location with a hyperechoic and arc-like surface and posterior acoustic shadowing. (Pediatr Surg Int 2010;26[5]:457.) CT is the most sensitive modality for detecting bezoar, which will appear as a well-defined intraluminal mass containing air or oral contrast.

Further examination utilizing ultrasound or CT is recommended because of their higher sensitivity. Small bezoars can be managed conservatively and will pass spontaneously. Larger bezoars, especially ones causing obstructive symptoms, will usually require surgical intervention.

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