What is your diagnosis?

[quackdoc]

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A 73 year old man suffering from chronic psychosis for the past 15 years has complaints of loss of appetite and persistent vomitting.The vomitus is non foul smelling,non projectile,not bile stained.General physical examination shows pallor and patchy loss of hair.There is no pedal edema,no cyanosis no clubbing,no lymphadenopathy.
Systemic examination shows ectatic stomach with a lump felt in the epigastric region.Rest of the abdominal examination is normal.
No other palpable masses.
Lab tests show a sodium levels as 130 meq/l,Pottasium 3.5meq/l.no proteinuria,no glycosuria,liver function tests within normal limits.
Barium meal shows irregular knotty mass in the stomach.
What further tests would you do ?
What is the presumptive diagnosis?
What is the further course of management?
Post your answers here.

 

[Kalel]

It sounds like your patient has a gastric outlet obstruction. Malignancy is one possiblility, benign gastric polyps, PUD with associated fibrosis and stricturing are other possibilities. Given his age, and the associated mass felt in the epigastric area, I would say that gastric carcinoma would be the most likely diagnosis. I'm not certain why you made your patient psychotic, but maybe that could be tied in with his disease pathology because people with schiz are likely to smoke which could predispose him to gastric carcinoma? I would explain his hyponatremia and hypokalemia with his persistent vomiting and associated dehydration. He may develop a metabolic alkalosis if he continues vomiting. The best test to order here would be to call GI for an upper GI endoscopy. I would give the patient fluids and potassium to correct his electrolytes abnormalites, place an NG tube to decompress and start him on IV PPI's while waiting for GI to arrive. Thanks for posting this case, be sure to check out my case in the IM forum as well.

 

[Jim Picotte]

Would have to see the images from the UGI, but with an irregular mass in the stomach gastric carcinoma is number one on your list. Sounds like it's near the cardia or fundus. Sometimes esophageal adenocarcinoma can invade the stomach as well. I guess you'd include metastasis and possibly lymphoma in the differential but they have a different appearance than what you described. A GIST is submucosal and has a smooth appearance but you could stick this in the differential.

You'd do an EGD with biopsy for confirmation and likely and abdominal/pelvic CT to look for lymph nodes and possible metastatic spread. You'd then cut it out.

 

[omores]

Hmmm. Psychotic. Patchy hair loss. Symptoms of gastric outlet obstruction. Knotty mass in stomach.

What if it's not a neoplasm, but rather something ingested that's gotten stuck? Like lots and lots of hair? I remember seeing a spectacular pic in a pathology book of a giant hairball removed from the stomach of a psychotic woman. The fancy term for it is bezoar.

Next step, endoscopy to verify, then removal via endoscope or surgically, depending on size and, er, density of the packed hair.

 

[Kalel]

Originally posted by omores
Hmmm. Psychotic. Patchy hair loss. Symptoms of gastric outlet obstruction. Knotty mass in stomach.

What if it's not a neoplasm, but rather something ingested that's gotten stuck? Like lots and lots of hair? I remember seeing a spectacular pic in a pathology book of a bezoar removed from the stomach of a psychotic woman: a giant hairball.

I thought that you were just joking until I looked up trichotillomania (hair pulling) in emedicine.com:
"In addition, trichophagia (ie, mouthing and/or ingesting hair) is common in persons who pull out their hair. This chewing or mouthing behavior frequently can lead to the formation of trichobezoars (ie, hair casts) in the stomach or small intestines. Trichobezoars can result in anemia, abdominal pain, hematemesis, nausea and/or vomiting, bowel obstruction, perforation, gastrointestinal (GI) bleeding, acute pancreatitis, and obstructive jaundice."😱

 

[KyGrlDr2B]

I say he's pulling his hair out and eating it.

 

[quackdoc]

Thanks for the reply.
The reason that I put this case up for discussion was the reason that it is gastric outlet obstruction but not due to gastric carcinoma.Even though it may look like that.Remember there is no evidence of any lymphadenopathy.
The patchy loss of hair with a case of chronic psychosis is important.
This belongs to a rare case of TRICHOBEZOARS whereby the patient ingests his/her own hair.
This belongs to a category called as RAPUNZEL SYNDROME.Type it in google search and you shall be directed to the relevant web sites.
The mass felt at the epigastrium is the "hair ball".The ectatic stomach indicates the mobility of the "mass per abdomen".
The signs and symptoms and age may closely mimic the gastric carcinoma.Yet this case has been highlighted just to point the existence of other differntial diagnosis.Since the history of chronic psychosis is a clear pointer here.
Further investigation includes upper GI endoscopy.The hair ball warrants surgical removal.
The topic has been discussed in Bailey and Love's surgery
By the way this was the question that was asked in NEJM as a medical mystery.I am sorry I have lost the link.But look in the
archives for jan2004.
I wanted to share this case study with everyone
here on this forum.

 

[omores]

Originally posted by KyGrlDr2B
I say he's pulling his hair out and eating it.

Exactly. Ick.

 

[Kalel]

Nice catch omores and kygrldr2b. 😉

 

[omores]

Thanks for the case!

Here's a discussion I found. Scroll down and check out the picture at the bottom. These things can get huge!
trichobezoar

 

[Galaxian]

Non-foul smelling vomitus...that's a new one...

 

[KyGrlDr2B]

There's a pic of this somewhere in robbins, I think.

 

[DrQuinn]

I've actually seen a few cases of trichotillomania in the ED (I've seen probably 3-4). Most are people of lower SES, with a history of psychiatric disorders (depression, anxiety, bipolar disorder). All my patients admitted to me to being sexually abused throughot their lives. Interesting.

Q, DO

 

[quackdoc]

Being sexually abused is intresting phenomenon in this case.I never knew it could be possible.As to the post on the non foul smelling vomitus I feel in cases where the large intestine perforates in the stomach maybe either due to crohns or ulcerative colitis or long standing carcinoma of the bowel wall..its quite possible that vomitus may be feaculent.Now its not a very bright idea but I guess that it has been discussed in Bailey and Love somewhere.
Please add to the post your experiences or any other cases that you might have come across.Since I am not based in US id like to know what kind of unusual cases one that comes across.