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COMPOSITE GASTRODUODENAL BEZOAR WITH RAPUNZEL SYNDROME

A 30-year-old man presented with epigastric pain of 5 months duration. Threemonths later he developed recurrent non-bilious vomiting suggestive of gastric outlet obstruction. He was mentally retarded. He had undergone two laparotomies at the age of 10 and 25 years for ingestion of foreign bodies. Examination of abdomen showed a well-defined non-tender mass. His haematological and biochemical work-up was normal. Upper gastrointestinal (GI) endoscopy showed a bezoar extending from the antrum to the pylorus and obstructing it. Plain radiograph of the abdomen showed multiple linear shadows in the stomach and duodenum and a suggestion of a mottled appearance in the antrum and duodenum (Fig. 1). A barium contrast study showed a classical mottled intraluminal filling defect with bariumfilled interstices suggestive of a bezoar (Fig. 2). The bezoar was extracted at laparotomy by an anterior gastrotomy, by taking care not to fragment it during removal (Fig. 3). The ‘composite’ bezoar consisted of a core of electric cables surrounded by undigested food material and extended from the antrum to the upper jejunum. Bezoars are collections or concretions of indigestible foreign material that accumulate and coalesce in the gastrointestinal tract, usually the stomach. Depending on their content they are classified as phytobezoar, trichobezoar, lactobezoar, pharmacobezoar and concretions of foreign material bezoars.1 Mental retardation and other psychiatric illnesses are often associated. This results in abnormal ingestion of hair, food material or foreign bodies. Prior gastric surgery, diabetes mellitus, and end-stage renal disease are other predisposing factors. Whether the ‘composite’ bezoar in our patient was a foreign body or a bezoar can be debated. Its location, nature and behaviour were like that of a bezoar and we have classified it accordingly.2 The range of clinical manifestations extend from the asymptomatic to nutritional deficiencies to surgical emergencies, which include GI bleeding, gastric outlet obstruction, perforation, small bowel obstruction, obstructive jaundice and pancreatitis. Contiguous extension of the bezoar into the small bowel leads to Rapunzel syndrome as was seen in our patient.3 Investigations include plain X-ray abdomen, especially in cases of obstruction. It can show gastrointestinal masses, dilated intestinal loops, air fluid levels and thickened bowel in case of complications arising from the bezoar. Barium studies show intraluminal filling defect with barium-filled interstices (mottled appearance) and no attachment to the bowel wall.4 Computed tomography scan is being increasingly used to diagnose bezoars. The essentials of treatment are removal and prevention of recurrence. Endoscopic removal with fragmentation and dissolution