[size=6]The abdominal radiograph below was obtained on an 11-year-old girl presenting with abdominal pain and a history of decreased appetite and a five pound weight loss over the past two weeks. What is the best next step in this child’s management?

 

 

a Laparotomy

 

b Enzymatic digestion

 

c Upper endoscopy

 

d Miralax

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C?

C

C

C

C

The radiograph appears to show a large, mottled intragastric mass outlined by gas, suggesting a bezoar. In an adolescent girl presenting with abdominal pain, decreased appetite, and weight loss, a trichobezoar, an accumulation of swallowed hair, is particularly likely. Upper gastrointestinal endoscopy confirms the diagnosis and assesses any associated gastric injury.

correct answer

a Laparotomy

 

This film demonstrates a gastric trichobezoar. These masses are often large, firm, and entwined. They may extend past the stomach into the duodenum (Rapunzel syndrome) or there may be several located throughout the small intestine. Trichobezoars are not usually amenable to enzymatic or endoscopic therapy because of their size, and are most commonly removed via gastrotomy. Children with trichobezoars require a consultation with psychiatry to address their trichotillomania, a habit disorder, to reduce the risk of recurrence. In the case presented, the mass is in the stomach and Miralax is not likely to be helpful. There are case reports of laparoscopic removal.