Presentation
Sudden onset abdominal pain.
Patient Data
Free air under the diaphragm denoting a pneumoperitoneum. No lung opacity and no pneumothorax or pleural effusion.
Pneumoperitoneum confirmed by CT. The source is the stomach, which is grossly distended with an intermediate density 'mass' within the lumen, heterogeneous in appearance. The wall of the stomach is thickened, particularly along the lesser curve, and there is focal breach of the wall indicating a likely perforated ulcer here.
Following the imaging, a repeat history was acquired and the patient indicated a tendency to chew on her hair, so this was diagnosed as a trichobezoar.
Surgery consisted of an emergency laparotomy, repair of gastric ulcer and removal of the trichobezoar.
PATHOLOGY
Macroscopic:
Gastric ulcer from upper body of stomach.
Microscopic:
Microscopy shows necrotic tissue and inflammatory exudate, with fat and peritoneum containing congested vessels and showing marked active chronic inflammation. Within the necrotic material, there are occasional fragments of food debris, indicating perforation of the gastrointestinal tract. There is no histological indication of the cause. There is no dysplasia and no evidence of malignancy.
Conclusion:
Gastric ulcer - perforation and necrosis with reactive mesothelium.
Case Discussion
Chronic inflammation of the gastric mucosa by the hairball ('trichobezoar') has led to ulcer formation and subsequent perforation with frank pneumoperitoneum. There was an uneventful recovery following surgery to remove the bezoar and ulcer.