Trichobezoar

A trichobezoar is a mass of cumulated hair within the gastrointestinal tract. Trichobezoar usually occurs in patients with trichotillomania history, it is characterized by a compulsive behavioral disorder of pulling one's hair, combined with trichophagia that consists of ingesting that hair ; it typically occur in the stomach and rarely affects the small intestine. It is also a cause of small bowel obstruction.

Bezoars are foreign bodies in the lumen of the digestive tract. The lumen size increases in time by the accumulation of ingested nonabsorbable food or fibers. Baudamant reported the first case of a human trichobezoar in 1779. In 1896, Stelzner described the first correct preoperative diagnosis of trichobezoar on the basis of physical examination. Bakey and Ochsner reviewed published literature and showed that 171 cases of trichobezoar, 119 cases of phytobezoar, and 13 cases of other concretions were reported. Schonborn performed the first surgical removal of a trichobezoar in 1883.

The bezoar is mostly caused by the presence of indigestible substance in the lumen. Some substances encourage stickiness and concrete formations. Bezoar occurs mainly in young women, who chew and swallow their hair (trichobezoar), vegetable fibers (phytobezoar), persimmon fibers (diospyrobezoar), or semi-liquid masse of drugs (pharmacobezoar).During the time, these substances are retained by mucus and become enmeshed; this yields a mass having the shape of the stomach localization where they are usually found.These substances attend large size due to the chronicity and delayed investigation of the affection. The age of occurrence of bezoars has been reported to range between 1 and 56 years old; the most dominant fraction of age is comprised between 15 and 20 years old with 90% of females. About 10% of patients have shown psychiatric abnormalities or mental retardation. Although about 1 of 2000 children suffer from trichotillomania, trichophagia is rarely seen, and a bezoar does not occur in all children with trichophagia. Bezoars mostly originate at the level of the stomach,it is probably related to high fat diet causing unspecific symptoms like epigastric pain, dyspepsia, and postprandial fullness. The stomach is not able to exteriorize hair and other substance out of the lumen because the friction surface is not sufficient for propulsion by peristalsis. The bezoars might also occur with GI bleeding (6%) and intestinal obstruction, or perforation (10%). The term "Rapunzel syndrome" was assigned to trichobezoars extending continuously through the entire length of the small intestine as a tail and was first described by Vaughan et al. in 1968.

Primary small bowel bezoars without any associated gastric bezoar are uncommon. Small bowel obstructions caused by bezoars, which rise within small bowel diverticula were reported. A decade later, a neonatal resection was performed for intestinal atresia. Recently, Carmon et al. described two cases of small bowel obstruction from bezoar formation in dilated jejunum. Reduced intestinal mortality is the most quoted factor in the intestinal bezoar formation. This last one is usually caused by a portion of the gastric trichobezoar which became detached to cause small or large bowel obstruction. In rare cases, it is caused by the trichobezoar itself such is the case for our patient. The most common sites of obstruction are the gastric outlet, or duodenum. Obstructions of distal parts of the small bowel or the large bowel are extremely rare. Biological investigations might show anemia. It is well demonstrated that iron deficiency anemia is rather a result and not a cause of trichophagy; this was established since the iron level was normal in most patients with trichotillomania and trichophagy. The examination of the hair content in stool would establish the diagnosis, but usually it is not done.

Various imaging modalities have been recommended for detection of bezoars. The imaging findings are helpful in diagnosing trichobezoar. The conventional radiography shows a masse of opaque soft tissue in a swollen stomach. A calcified rim may delineate the edge of the bezoar.The ultrasonography shows a typical curvilinear trichobezoar with bright echogenic band, this does not allow transmitting the ultrasound waves which generate a shadow over the left upper quadrant. The high echogenicity of hair and the presence of multiple acoustic interfaces created by trapped air and food limits the ultrasonography of the trichobezoars.

Both, the contrast radiography and the endoscopy of the upper GI tract are the diagnostic procedures of choice for establishing the diagnosis. The upper GI contrast radiography confirms the existence of the trichobezoar and might detect other complications such as gastric ulcers. In addition, the upper endoscopy is definitively the diagnostic support for trichobezoar; it might be used for endoscopic retrieval of proximal small trichobezoars. The computed tomography (CT-scan) is the most useful diagnostic tool in patients with bezoars because it reveals the localization of the bowel obstruction; it shows also a well-defined intralumina mass of the bezoar in the transitional zone of the obstruction. A mottled gas pattern in the mass is reported characterizing the bezoar, and it is supposed to be air bubbles retained within the bezoar.

Recently, researchers have recommended magnetic resonance imaging (MRI) for the evaluation of small-bowel disease. Fast imaging techniques coupled with advantages of breath holding improved MRI visualization of bezoars. Therefore, MRI is found to be better support for determining both the site and the cause of small-bowel obstructions. MRI shows the bezoar as a mass in the small bowel containing mottled and confluent low signal intensities on both T1- and T2-weighted MR images.

The treatment consists of removing the mass by a single enterotomy or resection of the bowel if not feasible. Duncan et al. recommended bezoar extraction by multiple enterotomies in the Rapunzel syndrome. DeBakey and Oschner reported a surgical mortality of 10.4%. It is mandatory to perform a thorough exploration of all the small intestine and the stomach searching for retained bezoars.

The endoscopic examination is the preferred method of investigating the stomach when available; this allows searching for an associated bezoar while managing an intestinal bezoar. This exploration may reveal concomitant gastric bezoar which may be retrieved using endoscopy or gastrotomy approaches.Escamilla et al. reported 23 cases of associated gastric bezoars extracted by gastrotomy over 87 cases of intestinal bezoars. The psychiatric follow-up is essential to prevent recurrences.

Maggot Therapy

History of Maggot Therapy
Maggots have been known for centuries to help heal wounds. Military surgeons noted that soldiers whose wounds became infested with maggots had better outcomes than those not infested. William Baer, while at Johns Hopkins University in Baltimore, Maryland, may have been the first in the Northern Hemisphere to have intentionally applied larvae to wounds in order to induce wound healing. During the late 1920's, he identified specific species, raised them in the laboratory, and used their larvae to treat several children with osteomyelitis and soft tissue infections. He presented his findings at a surgical conference in 1929. Two years later, after treating 98 children, his findings were published posthumously.
MDT was successfully and routinely performed by thousands of physicians throughout the 1930’s, but soon it was supplanted by the new antibiotics and surgical techniques that came out of World War II. Maggot therapy was occasionally used during the 1970's and 1980's, but only when antibiotics, surgery, and modern wound care failed to control the advancing wound.
The first modern clinical studies of maggot therapy were initiated in 1989, at the Veterans Affairs Medical Center in Long Beach, CA, and at the University of California, Irvine, to answer the following questions:
"Is maggot therapy still useful today?"
"Should maggot therapy be used as an adjunct to other treatments, not merely as a last resort?"
"How does maggot therapy compare to other treatments at our disposal?"
The results of those controlled comparative clinical trials and the many studies and reports that followed, indicate that MDT is still useful today as a safe and effective treatment tool for some types of wounds. Those studies also demonstrated that there is no reason to withhold MDT until all other modalities have been exhausted, nor use it only as a “last resort.” Indeed, while published accounts of “pre-amputation MDT” show a limb salvage rate of over 40%, the success of MDT when used earlier in the course of treatment (say, as a 2nd or 3rd or 4th line treatment) is even more dramatic.
Current status of maggot therapy
In 1995, a handful of doctors in 4 countries were using MDT. Today, any physician in the U.S. can prescribe maggot therapy. Over 4,000 therapists are using maggot therapy in 20 countries. Approximately 50,000 treatments were applied to wounds in the year 2006.
In January 2004, the U.S. Food and Drug Administration (FDA) began regulating medicinal maggots, and allowed the production and marketing of one particular strain of Phaenicia sericata larvae marketed under the brand name Medical Maggots (TM). In February, 2004, the British National Health Service (NHS) permitted its doctors to prescribe maggot therapy. Patients no longer have to be referred to one of a few regional wound-specialty hospitals to get maggot treatments.
The BioTherapeutics, Education & Research Foundation was established in 2003 for the purpose of supporting patient care, education, and research in maggot therapy and the other forms of symbiotic medicine (diagnosing and/or treating diseases with live animals, such as maggot therapy, leech therapy, honey bee therapy, pet therapy & sniffer dogs, ichthiotherapy, bacteriotherapy etc).
Biology of flies and maggots
Maggots are fly larvae, or immature flies, just as caterpillars are butterfly or moth larvae. Maggots do not appear all by themselves ("de novo"), as was believed 150 years ago; they hatch from eggs, laid by adult female flies.
Not all species of flies are safe and effective as medicinal maggots. There are thousands of species of flies, each with its own habits and life cycle. Some fly larvae feed on plants or animals, or even blood (i.e., mosquitoes). Others feed on rotting organic material.
Those flies whose larvae feed on dead animals will sometimes lay their eggs on the dead parts (necrotic or gangrenous tissue) of living animals. When maggots are infesting live animals, that condition is called “myiasis.” Some of those maggots will feed only on dead tissue, some only on live tissue, and some on live or dead tissue. The flies used most often for the purpose of maggot therapy are "blow flies" (Calliphoridae); and the species used most commonly is Phaenicia sericata, the green blow fly.
A diagram and photograph of a typical blow fly life cycle appears below

Advantages and disadvantages of maggot debridement therapy (“MDT")
Efficacy, as demonstrated in several small but significant controlled clinical studies.
Takes about 15-30 minutes to apply a secure dressing to keep the maggots in place.
Excellent safety record.
Maggots are highly perishable and should be used within 24 hours of arrival.
Simple enough that non-surgeons can use it to provide thorough debridement when surgery is not available or is not the optimal choice. This means that it is also possible to provide surgical quality debridement as an outpatient or in the home.
Low cost of treatment

Thus, Maggot therapy is an effective, accepted method of treating chronic, non-healing wounds. Only specially selected, tested, disinfected larvae are applied to the wound surface and covered with a dressing that prevents the larvae from escaping. They are easily and completely removed 2 or 3 days later. Sometimes the wound is completely cleaned by then; sometimes additional treatments may be necessary. After maggot therapy, the wound may be clean enough to close, cover, graft, or flap. Your doctor will be able to suggest the best treatment to follow.

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