Case presentation -including intra operative photos- of a giant gastric trichobezoar presenting as an acute abdomen due to perforated gastric ulcer dealt with by the author.

1. DR. MOHAMAD AL-GAILANIDR. MOHAMAD AL-GAILANI FRCSFRCS
CONSULTANT SURGEONCONSULTANT SURGEON
HEADDEPARTMENT OF SURGERYHEADDEPARTMENT OF SURGERY
IN-CHARGE MEDICAL EDUCATION & TRAININGIN-CHARGE MEDICAL EDUCATION & TRAINING
AL HAMMADI HOSPITAL, NUZHAAL HAMMADI HOSPITAL, NUZHA
RIYADH, KSARIYADH, KSA

2. • EMERGENCY ROOM PRESENTATIONEMERGENCY ROOM PRESENTATION
• 22 YEAR OLD FEMALE22 YEAR OLD FEMALE
• SUDDEN ONSETSUDDEN ONSET
• GENERALIZED ABDOMINAL PAINGENERALIZED ABDOMINAL PAIN
• WOKE HER UP FROM SLEEPWOKE HER UP FROM SLEEP
• INCREASES ON MOVEMENTINCREASES ON MOVEMENT
• ASSOCIATED WITH VOMITINGASSOCIATED WITH VOMITING
22

3. PAST MEDICAL HISTORYPAST MEDICAL HISTORY
• 2-3 WEEKS HISTORY EPIGASTRIC PAIN2-3 WEEKS HISTORY EPIGASTRIC PAIN
• NO PREVIOUS SURGERYNO PREVIOUS SURGERY
• FIT OTHERWISEFIT OTHERWISE
• ON NO MEDICATIONSON NO MEDICATIONS
• NO KNOWN ALLERGIESNO KNOWN ALLERGIES
33

4. • TEMP 37.3 C, PULSE 98/MIN, RR 16/MIN, BP 80/40 MM HGTEMP 37.3 C, PULSE 98/MIN, RR 16/MIN, BP 80/40 MM HG
• PATIENT WAS IN OBVIOUS PAIN, DEHYDRATED, NO PALLORPATIENT WAS IN OBVIOUS PAIN, DEHYDRATED, NO PALLOR
• ABDOMEN: ACUTE ABDOMENABDOMEN: ACUTE ABDOMEN
• GENERALIZED TENDERNESS, WITH RIGIDITY AND GUARDING.GENERALIZED TENDERNESS, WITH RIGIDITY AND GUARDING.
BOWEL SOUNDS SLUGGISHBOWEL SOUNDS SLUGGISH
• REST OF THE SYSTEMIC EXAMINATION WAS UNREMARKABLE.REST OF THE SYSTEMIC EXAMINATION WAS UNREMARKABLE.
44

5. • HB 13.3HB 13.3
• WCC 17.1WCC 17.1
• UREA & ELECTROLYTES: NORMALUREA & ELECTROLYTES: NORMAL
• LIVER FUNCTION TESTS: NORMALLIVER FUNCTION TESTS: NORMAL
• ERECT CHEST X-RAY & ABDOMINAL X-RAY: AIR UNDERERECT CHEST X-RAY & ABDOMINAL X-RAY: AIR UNDER
DIAPHRAGMDIAPHRAGM
55

6. • ACUTE ABDOMENACUTE ABDOMEN
• DIAGNOSIS: PERFORATED VISCOUSDIAGNOSIS: PERFORATED VISCOUS
• TREATMENT: RESUSCITATION, IV FLUIDS, IV ANTIBIOTICS,TREATMENT: RESUSCITATION, IV FLUIDS, IV ANTIBIOTICS,
ANAESTHETIC ASSESSMENTANAESTHETIC ASSESSMENT
• EMERGENCY LAPAROTOMYEMERGENCY LAPAROTOMY
66

7. OPERATIVE FINDINGSOPERATIVE FINDINGS
• GASTRIC LESSER CURVE ULCER-PERFORATIONGASTRIC LESSER CURVE ULCER-PERFORATION
• LARGE INTRA GASTRIC MASSLARGE INTRA GASTRIC MASS
77

8. INTRA-OPERATIVE FINDINGS:INTRA-OPERATIVE FINDINGS:
LESSER CURVE STOMACH ULCER-LESSER CURVE STOMACH ULCER-
PERFORATIONPERFORATION
88
DR. AL-GAILANI FRCS

9. OPERATIVE PROCEDUREOPERATIVE PROCEDURE
• PERITONEAL TOILET/SUCTION & MOPPING ESCAPED GASTRICPERITONEAL TOILET/SUCTION & MOPPING ESCAPED GASTRIC
CONTAINTCONTAINT
• GASTROTOMY BETWEEN TWO STAY SUTURESGASTROTOMY BETWEEN TWO STAY SUTURES
• EXTRACTION OF A LARGE INTRA GASTRIC MASSEXTRACTION OF A LARGE INTRA GASTRIC MASS
• GASTROTOMY CLOSED IN 2 LAYERS WITH 2/0 PDSGASTROTOMY CLOSED IN 2 LAYERS WITH 2/0 PDS
• GASTRIC ULCER BIOPSIED AND PERFORATION CLOSED BY OVERGASTRIC ULCER BIOPSIED AND PERFORATION CLOSED BY OVER
SEWING & COVERING WITH GREATER OMENTUMSEWING & COVERING WITH GREATER OMENTUM
• PERITONEAL LAVAGE WITH 3 LITRES NORMAL SALINE.PERITONEAL LAVAGE WITH 3 LITRES NORMAL SALINE.
99

10. GASTROTOMYGASTROTOMY
TWO STAY SUTURES INSERTEDTWO STAY SUTURES INSERTED
1010

11. 1111

12. 1212

13. POSTOPERATIVELYPOSTOPERATIVELY
• UNEVENTFUL RECOVERYUNEVENTFUL RECOVERY
• PATIENT CONFESSED TO EATING HER HAIR FOR SEVERAL YEARS!PATIENT CONFESSED TO EATING HER HAIR FOR SEVERAL YEARS!
• HISTOLOGY FROM THE ULCER BASE AND EDGE SHOWEDHISTOLOGY FROM THE ULCER BASE AND EDGE SHOWED
GRANULATION TISSUE WITH FIBRO-PURULENT EXUDATE ANDGRANULATION TISSUE WITH FIBRO-PURULENT EXUDATE AND
OEDEMATOUS CONGESTED STROMAL TISSUEOEDEMATOUS CONGESTED STROMAL TISSUE
• SEEN IN FOLLOW-UP: WELL WITH NO COMPLAINT.SEEN IN FOLLOW-UP: WELL WITH NO COMPLAINT.
1313

14. TRICHOBEZOARTRICHOBEZOAR

15. BEZOARBEZOAR
• A BEZOAR IS A BALL OF SWALLOWED FOREIGN MATERIALA BEZOAR IS A BALL OF SWALLOWED FOREIGN MATERIAL
(USUALLY HAIR) OR FIBRE THAT COLLECTS IN THE STOMACH(USUALLY HAIR) OR FIBRE THAT COLLECTS IN THE STOMACH
AND FAILS TO PASS THROUGH THE PYLORUSAND FAILS TO PASS THROUGH THE PYLORUS
• THE INCIDENCE IS VERY LOWTHE INCIDENCE IS VERY LOW
• THE RISK IS GREATER AMONG MENTALLY HANDICAPPED ORTHE RISK IS GREATER AMONG MENTALLY HANDICAPPED OR
EMOTIONALLY DISTURBED CHILDREN.EMOTIONALLY DISTURBED CHILDREN.
• GENERALLY BEZOARS ARE SEEN IN FEMALESGENERALLY BEZOARS ARE SEEN IN FEMALES
(APPROXIMATELY 90%)(APPROXIMATELY 90%)
• AGED INCIDENCE 10 TO 19 YEARS.AGED INCIDENCE 10 TO 19 YEARS.
1515

16. PATHOGENESISPATHOGENESIS
• THE PRESENCE OF INDIGESTIBLE MATERIAL IN THETHE PRESENCE OF INDIGESTIBLE MATERIAL IN THE
LUMEN.LUMEN.
• CHEWING ON OR EATING HAIR OR FUZZY MATERIALSCHEWING ON OR EATING HAIR OR FUZZY MATERIALS
OR INDIGESTIBLE VEGETABLE FIBRE.OR INDIGESTIBLE VEGETABLE FIBRE.
• GASTRIC DYSMOTILITY INCLUDING PREVIOUSGASTRIC DYSMOTILITY INCLUDING PREVIOUS
SURGERY LIKESURGERY LIKE VAGOTOMY, PYLOROPLASTY,VAGOTOMY, PYLOROPLASTY,
ANTRECTOMY OR PARTIAL GASTRECTOMYANTRECTOMY OR PARTIAL GASTRECTOMY..
• POOR GASTRIC MOTILITY SUCH AS MIGHT OCCUR INPOOR GASTRIC MOTILITY SUCH AS MIGHT OCCUR IN
DIABETIC AUTONOMIC NEUROPATHYDIABETIC AUTONOMIC NEUROPATHY
1616

17. CLINICAL FEATURESCLINICAL FEATURES
• MAY BE ASYMPTOMATICMAY BE ASYMPTOMATIC
• ANOREXIAANOREXIA
• BLOATINGBLOATING
• EARLY SATIETYEARLY SATIETY
• HISTORY OF TRICHOPHAGYHISTORY OF TRICHOPHAGY
• TRICHOPTYSIS: COUGHING UP OF HAIRTRICHOPTYSIS: COUGHING UP OF HAIR
1717

18. 1818

19. • OBSTRUCTIONOBSTRUCTION
• PRESSURE NECROSISPRESSURE NECROSIS
• ULCERATIONULCERATION
• PERFORATIONPERFORATION
• PERITONITISPERITONITIS
1919

20. • OBSTRUCTIVE JAUNDICEOBSTRUCTIVE JAUNDICE
• ACUTE PANCREATITISACUTE PANCREATITIS
• PROTEIN-LOSING ENTEROPATHYPROTEIN-LOSING ENTEROPATHY
• STEATORRHEASTEATORRHEA
• MECHANICAL SMALL BOWEL OBSTRUCTIONMECHANICAL SMALL BOWEL OBSTRUCTION
• PERFORATIONPERFORATION
2020

21. 2121

22. DECLARATIONDECLARATION
• THIS CASE WAS MANAGED BY THE AUTHORTHIS CASE WAS MANAGED BY THE AUTHOR DR. MOHAMAD AL-GAILANIDR. MOHAMAD AL-GAILANI FRCSFRCS
WHILE STILL PRACTICING AS A CONSULTANT SURGEON IN THE UNITEDWHILE STILL PRACTICING AS A CONSULTANT SURGEON IN THE UNITED
KINGDOM PRIOR TO COMMENCING WORK AT AL HAMMADI HOSPITAL,KINGDOM PRIOR TO COMMENCING WORK AT AL HAMMADI HOSPITAL,
RIYADH, KSA.RIYADH, KSA.
• THE PUBLISHED PHOTOS OF THE OPERATION ARE FROM HIS PERSONALTHE PUBLISHED PHOTOS OF THE OPERATION ARE FROM HIS PERSONAL
COLLECTION.COLLECTION.
2222
•
•