Plasticobezoar-another new entity for Rapunzel syndrome

Rapunzel syndrome in children: a retrospective review of ten cases combined with literature review in a tertiary referral center

PURPOSE

Rapunzel syndrome is an uncommon condition in children, and its clinical features remain unclear. This study presents the largest single-center series of pediatric cases to date, with the objective of documenting the clinical characteristics and treatment approaches for children with Rapunzel syndrome.

METHODS

A retrospective study was conducted in children with Rapunzel syndrome from 2019 to 2023. We recorded age, gender, symptoms, locations of bezoar, complications, and treatment options.

RESULTS

Ten patients with Rapunzel syndrome were included. The median age was 9.1 years, with all of whom were female. The most common clinical symptoms were upper abdominal mass (90%), abdominal pain (80%), and nausea and vomiting (50%). Complications occurred in six cases (60%), including small bowel obstruction (20%), severe gastric dilatation (10%), intestinal perforation (10%), choledochodilation (10%), acute pancreatitis with cholecystitis (10%). Preoperative ultrasonography suggested low-echoic foreign bodies continuing to the jejunum or ileocecal region in five cases (50%). Preoperative gastroscopy attempted in four cases (40%) to remove the foreign bodies, all of which failed. All patients underwent surgical treatment, with nine cases undergoing gastric incision foreign body removal, and one case undergoing gastric incision foreign body removal combined with intestinal perforation repair. All patients recovered well. No recurrence was observed during follow-up.

CONCLUSION

The accuracy of ultrasound diagnosis in identifying Rapunzel syndrome is high; however, it may lead to misdiagnosis if not complemented with the patient's medical history. Endoscopic presents a heightened treatment risk and a reduced success rate. The condition commonly presents with severe complications, thus making laparotomy a safe and effective option for intervention.

A computed tomography phantom study of foam earplugs: Uncommon but potentially hazardous foreign body ingestion in children

Ingestion of a foreign body is common among children. However, ingestion of foam earplugs (FEPs) has not been reported previously. A 7-month-old female infant presented with small bowel obstruction, which was finally proved to be a case of FEP ingestion.Computed tomography (CT) phantom study was performed to examine the imaging features of FEPs. We studied the following dry and fully wet FEPs, FEPs squeezed in pure water to varying degrees, and FEPs with different degrees of compression in the dry and wet states from day 0 to 6 and all scanned with a CT scanner.The density of a dry FEP is -843.5 ± 4.5 Hounsfield units (HU) and it increases to 0.76 ± 9.3 HU when fully wet. The densities of FEPs ranged from -844.2 to 1.0 HU with different water/air ratios, and some showed a heterogeneous geographic pattern. The densities of FEPs increase due to compression and gradual water absorption.FEPs can be potentially hazardous objects to children. Owing to the special foam structure of the FEP, it can mimic a fatty lesion if the density ranges from -100 to -50 HU; moreover, it can hide in the water if fully wet. However, it should not be mistaken as air, as the density of a dry FEP is -843.5 HU, and the contour can be observed if the window level is set appropriately. Because of its soft texture, the surgeon should be careful not to miss an FEP during the operation. Moreover, radiologists should be familiar with the CT features of FEPs so that they can be identified before surgery.

X-ray detection of ingested non-metallic foreign bodies

AIM: To determine the utility of X-ray in identifying non-metallic foreign body (FB) and assess inter-radiologist agreement in identifying non-metal FB.

METHODS: Focus groups of nurses, fellows, and attending physicians were conducted to determine commonly ingested objects suitable for inclusion. Twelve potentially ingested objects (clay, plastic bead, crayon, plastic ring, plastic army figure, glass bead, paperclip, drywall anchor, eraser, Lego™, plastic triangle toy, and barrette) were embedded in a gelatin slab placed on top of a water-equivalent phantom to simulate density of a child’s abdomen. The items were selected due to wide availability and appropriate size for accidental pediatric ingestion. Plain radiography of the embedded FBs was obtained. Five experienced radiologists blinded to number and types of objects were asked to identify the FBs. The radiologist was first asked to count the number of items that were visible then to identify the shape of each item and describe it to a study investigator who recorded all responses. Overall inter-rater reliability was analyzed using percent agreement and κ coefficient. We calculated P value to assess the probability of error involved in accepting the κ value.

RESULTS: Fourteen objects were radiographed including 12 original objects and 2 duplicates. The model’s validity was supported by clear identification of a radiolucent paperclip as a positive control, and lack of identification of plastic beads (negative control) despite repeated inclusion. Each radiologist identified 7-9 of the 14 objects (mean 8, 67%). Six unique objects (50%) were identified by all radiologists and four unique objects (33%) were not identified by any radiologist (plastic bead, Lego™, plastic triangle toy, and barrette). Identification of objects that were not present, false-positives, occurred 1-2 times per radiologist (mean 1.4). An additional 17% of unique objects were identified by less than half of the radiologists. Agreement between radiologists was considered almost perfect (kappa 0.86 ± 0.08, P < 0.0001).

CONCLUSION: We demonstrate potential non-identification of commonly ingested non-metal FBs in children. A registry for radiographic visibility of ingested objects should be created to improve clinical decision-making.

Tricholithobezoar causing gastric perforation

A bezoar is an intraluminal mass formed by the accumulation of undigested material in the gastrointestinal tract. Trichobezoar is a rare condition seen almost exclusively in young women with trichotillomania and trichotillophagia. When not recognized, the trichobezoar continues to grow, which increases the risk of severe complications such as gastric ulceration and even perforation. Formation of a gallstone within the trichobezoar (tricholithobezoar) is an event that has not yet been described. We report the case of a 22-year-old woman admitted to the emergency room with signals and symptoms of an epigastric mass and perforative acute abdomen. Radiological study revealed bilateral pneumoperitoneum. Personal history revealed depressive syndrome, trichotillomania and trichophagia. With a diagnosis of visceral perforation, an urgent exploratory laparotomy was performed. This confirmed the diagnosis of gastric perforation due to a large trichobezoar with the formation of a gastrolith that was removed by anterior gastrotomy. Biochemical study of the gastric stone revealed that it was composed of bile salts. There were no complications. The patient was discharged on the 5th postoperative day and was referred for psychiatric treatment.