Trichobezoar Causing Obstruction of a Percutaneous Endoscopic Gastrostomy (PEG) Feeding Tube: A Case Report

TL;DR

A 29-year-old woman with learning disabilities had a trichobezoar (hairball) obstructing her feeding tube, highlighting the need to consider this rare condition in similar patients.

Contribution

This case report adds to the limited literature on trichobezoars causing PEG tube obstruction and emphasizes the importance of considering psychiatric comorbidities.

Findings

A trichobezoar was found obstructing a PEG feeding tube in a young female with psychiatric disorders.

Endoscopic retrieval of the trichobezoar was successful under general anesthesia.

Trichobezoars should be considered in the differential diagnosis for GI obstructions in patients with psychiatric conditions.

Abstract

Trichobezoar (hairball) is a rare condition that may pose a diagnostic challenge. Trichobezoar is prevalent in young females with psychiatric disorders. It is defined as a compact mass of ingested hair that accumulates within the gastrointestinal (GI) tract, most commonly in the stomach, and can sometimes extend into the intestines. Its formation occurs because hair is indigestible and tends to mat together over time, creating a dense, often obstructive mass. When a trichobezoar extends beyond the duodenum, the condition is referred to as Rapunzel syndrome. Trichobezoars are often associated with behavioral disorders such as trichotillomania (hair-pulling) and trichophagia (hair-swallowing), which may occur unconsciously or as part of impulse control disorders. This condition is particularly prevalent among adolescent females with psychiatric disorders.

A 29-year-old female with learning disabilities presented to her general practitioner with an obstructed percutaneous endoscopic gastrostomy (PEG) feeding tube and was referred for an elective gastroscopy for a presumed dislodged PEG tube. During the procedure, a foreign body resembling a kitchen scrubber was identified, causing partial obstruction of the duodenal bulb (D1) and the second part of the duodenum (D2) and resulting in ulceration in D2. The foreign body was stuck to the inner part of the PEG tube. The endoscopist successfully freed the PEG tube and replaced it with a new one; however, multiple attempts to retrieve the foreign body were unsuccessful.

A post-procedural abdominal CT scan demonstrated a presumed metallic foreign body within the stomach, measuring approximately 8 mm in length and 4 mm in thickness. The case was discussed with the regional upper GI surgical team, who recommended a further attempt at endoscopic retrieval by a senior endoscopist in the operating theatre, with the local surgical team present, due to the risk of GI perforation or injury from the retained metallic foreign body. The patient underwent a gastroscopy under general anesthesia by an endoscopist surgeon who was able to retrieve the foreign body using a snare; it was identified as a trichobezoar. Patient recovered well post-procedure, and PEG feeding was resumed. Despite the rarity of trichobezoar, it should be included in the differential diagnosis of young female patients with psychiatric disorders.

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