Tangled

A 4-year-old girl presented with 1-year history of fatigue, early satiety, intermittent vomiting, alopecia, pallor, and weight loss without changes in bowel habits or overt gastrointestinal bleeding. Examination revealed thin hair, pale conjunctivae, and mu-cous membranes. Tachycardia and a systolic flow murmur (grade II/VI) were present. Abdomen was nontender, distended, and tympanitic, with hyperactive bowel sounds and a palpable mass in her left upper quadrant. Initial labs revealed iron deficiency anemia (hemoglobin 3.3 g/dL, mean corpuscular volume 48 FL, platelets 515 000, ferritin 1.6 ng/mL) and hypoalbuminemia 2.9 g/dL. She was transfused with packed red blood cells and parenteral iron. Abdomen computed tomography (Figure 1) revealed a large gastric bezoar extending into the duodenum and a localized air-filled out pouching of stomach wall abutting the surface of liver concerning for sealed perforation. There was no small bowel obstruction or free air. Upper endoscopy confirmed a large trichobezoar in the stomach. She underwent a laparot-omy with longitudinal gastrostomy and removal of the large trichobezoar (Figure 2). Intraoperative inspection showed ulceration over the fundus/body with contained perforation into the liver (segments 2/3). The patient did well postoper-atively and tolerated a regular diet prior to discharge. A Figure 1. Abdominal computed tomography showing gastric bezoar. Figure 2. Trichobezoar measuring 14 x 13 x 7.5 cm casted in the shape of the stomach, pylorus, duodenal bulb, and C-sweep.