Obstructive
Jaundice Due to Gastric Trichobezoar By Helmut Schreiber
and Howard
Cleveland,
C. F&ton
Ohio
Among the causes of obstructive jaundice. in childhood, a foreign body of the gastrointestinal tract is rare. Biliary tract obstruction can be caused by a foreign body large enough to occlude the periampullary portion of the duodenum and ampulla of Vater. When this occurs, obstructive symptoms of the proximal GI tract usually dominate the clinical picture. Gastric bezoars have been known to attain enormous size and frequently have “tails” that extend into the small bowel. Common complications of gastric and intestinal bezoars are obstruction, ulceration, and perforation, but biliary tract obstruction to our knowledge has not yet been reported. The atypical history and confusing laboratory tests in a jaundiced infant delayed diagnosis and treatment. CASE
REPORT
A previously
healthy l9-mo-old boy was admitted to Rainbow Babies and Children’s Hospital of Cleveland for evaluation of “hepatomegaly” and recent onset of jaundice. One week prior to admission the mother noted that the child was listless, less playful, and had a poor appetite. He gagged on solids but tolerated liquids. His lips and eyes were yellow. His urine was dark yellow and his stools were light tan in color. Two days before admission he was examined by his pediatrician who noted his “liver” to be enlarged and admitted him for evaluation of suspected hepatitis. Admission examination confirmed the “hepatomegaly” with a smooth, firm, rounded edge that was not tender. lcterus was no longer apparent and the color of the stools appeared normal. Laboratory findings included: Hematocrit, 40%; WBC, 10,000 with 25 neutrophils, 72 lumphocytes, and 3 monocytes; mono spot, negative; SGOT, 71 U; LDH, I90 U; total bilirubin, less than I mg/lOO ml; and alkaline phosphatase, 21.3 Bodansky units (normal up to 14 units). Prothrombin time was normal (I 1.9 control/9.9 patient). Urine urobilinogen was I Ehrlich unit. X-rays of the abdomen revealed an ovoid soft-tissue mass that extended transversely across the upper abdomen and appeared separate from the liver. From its appearance, a gastic bezoar was suspected. A GI series and the presence of hair in the stools supported our impression (Fig. IA).
Fig. 1. (A) Upper gartrointestinal series showing gastric bexoar. (6) gezoar with marked bile staining of duodenal portion of specimen (light area in photograph).
@ 1976 by Grune & Stratton.
Inc.
Journal of Pediatric Surgery, Vol. 11, No. 1 (February), 1976
103
CASE REPORTS
104
When the patient’s mother was specifically questioned, she recalled the child’s unusual habit of eating hair from hair brushes. It also became apparent that the enlarged “liver” palpated on admission was in fact the bezoar within the stomach. At exploration, a giant trichobezoar was removed from the stomach and proximal small intestine. A perfect cast of the stomach and duodenum was apparent and bile staining of the duodenal portion of the specimen was striking (Fig. 1B). The child was discharged after an uneventful postoperative course. The serum alkaline phosphatase level returned to normal (I I Bodansky units).
REFERENCES I. DeBakey M, Ochsner A: Bezoars cretions. Surgery 4: 934, 1938 2. DeBakey M, Ochsner A: Bezoars cretions. Surgery 5: 132, 1939 3. Small A, Allen M, Muehlbauer Obstructing giant trichobezoars
and conand conSylvain K: including
stomach and duodenal bulb. Am J Gastroenterol50:297-302, 1968 4. Smaller S, Schreiber H, Scott B: Trichobezoar as a cause of intestinal obstruction in a two and a half year old child. J Dis Child 82: 439,195l
Jaundice Due to Gastric Trichobezoar By Helmut Schreiber
and Howard
Cleveland,
C. F&ton
Ohio
Among the causes of obstructive jaundice. in childhood, a foreign body of the gastrointestinal tract is rare. Biliary tract obstruction can be caused by a foreign body large enough to occlude the periampullary portion of the duodenum and ampulla of Vater. When this occurs, obstructive symptoms of the proximal GI tract usually dominate the clinical picture. Gastric bezoars have been known to attain enormous size and frequently have “tails” that extend into the small bowel. Common complications of gastric and intestinal bezoars are obstruction, ulceration, and perforation, but biliary tract obstruction to our knowledge has not yet been reported. The atypical history and confusing laboratory tests in a jaundiced infant delayed diagnosis and treatment. CASE
REPORT
A previously
healthy l9-mo-old boy was admitted to Rainbow Babies and Children’s Hospital of Cleveland for evaluation of “hepatomegaly” and recent onset of jaundice. One week prior to admission the mother noted that the child was listless, less playful, and had a poor appetite. He gagged on solids but tolerated liquids. His lips and eyes were yellow. His urine was dark yellow and his stools were light tan in color. Two days before admission he was examined by his pediatrician who noted his “liver” to be enlarged and admitted him for evaluation of suspected hepatitis. Admission examination confirmed the “hepatomegaly” with a smooth, firm, rounded edge that was not tender. lcterus was no longer apparent and the color of the stools appeared normal. Laboratory findings included: Hematocrit, 40%; WBC, 10,000 with 25 neutrophils, 72 lumphocytes, and 3 monocytes; mono spot, negative; SGOT, 71 U; LDH, I90 U; total bilirubin, less than I mg/lOO ml; and alkaline phosphatase, 21.3 Bodansky units (normal up to 14 units). Prothrombin time was normal (I 1.9 control/9.9 patient). Urine urobilinogen was I Ehrlich unit. X-rays of the abdomen revealed an ovoid soft-tissue mass that extended transversely across the upper abdomen and appeared separate from the liver. From its appearance, a gastic bezoar was suspected. A GI series and the presence of hair in the stools supported our impression (Fig. IA).
Fig. 1. (A) Upper gartrointestinal series showing gastric bexoar. (6) gezoar with marked bile staining of duodenal portion of specimen (light area in photograph).
@ 1976 by Grune & Stratton.
Inc.
Journal of Pediatric Surgery, Vol. 11, No. 1 (February), 1976
103
CASE REPORTS
104
When the patient’s mother was specifically questioned, she recalled the child’s unusual habit of eating hair from hair brushes. It also became apparent that the enlarged “liver” palpated on admission was in fact the bezoar within the stomach. At exploration, a giant trichobezoar was removed from the stomach and proximal small intestine. A perfect cast of the stomach and duodenum was apparent and bile staining of the duodenal portion of the specimen was striking (Fig. 1B). The child was discharged after an uneventful postoperative course. The serum alkaline phosphatase level returned to normal (I I Bodansky units).
REFERENCES I. DeBakey M, Ochsner A: Bezoars cretions. Surgery 4: 934, 1938 2. DeBakey M, Ochsner A: Bezoars cretions. Surgery 5: 132, 1939 3. Small A, Allen M, Muehlbauer Obstructing giant trichobezoars
and conand conSylvain K: including
stomach and duodenal bulb. Am J Gastroenterol50:297-302, 1968 4. Smaller S, Schreiber H, Scott B: Trichobezoar as a cause of intestinal obstruction in a two and a half year old child. J Dis Child 82: 439,195l
