A 17-year-old girl with a history of trichotillomania presents with 6 months of progressive epigastric pain, early satiety, postprandial vomiting, and weight loss. On examination, an epigastric mass is palpable. Upper GI endoscopy reveals a large black matted mass occupying the entire stomach. The structure marked **A** in the diagram—the cast of hair in the stomach—is best described by which of the following statements regarding its composition and management?
A. It is a trichobezoar composed of matted hair and almost never responds to dissolution, often requiring surgical removal via gastrotomy in cases of this size
B. It is a pharmacobezoar composed of inspissated medication residue and requires proton pump inhibitor therapy to prevent recurrence
C. It is a trichobezoar composed of matted hair and typically responds well to endoscopic fragmentation and dissolution therapy with cola and cellulase
D. It is a phytobezoar composed of vegetable matter and persimmon seeds, which responds well to enzymatic dissolution with cellulase
Explanation
Why option 1 is correct
The structure marked A is a trichobezoar—a concretion of matted hair formed in patients with trichotillomania and trichophagia. Unlike phytobezoars (which respond to cola and cellulase), trichobezoars are composed of indigestible hair and almost never respond to dissolution therapy. In this case, the large size of the trichobezoar occupying the entire stomach, combined with the presence of a tail extending through the pylorus (Rapunzel syndrome), mandates surgical removal via open or laparoscopic gastrotomy. Endoscopic fragmentation may be attempted for small trichobezoars, but large ones like this require operative intervention. (Schwartz Principles of Surgery 11e; Naik et al. Rapunzel Review)
Why each distractor is wrong
Option 0: While trichobezoars can occasionally be managed endoscopically if small, large trichobezoars composed of matted hair do NOT respond to cola and cellulase dissolution—these agents work for phytobezoars, not trichobezoars. This conflates two different bezoar types.
Option 2: This describes a phytobezoar (vegetable matter, persimmons), not a trichobezoar. Phytobezoars occur in different clinical contexts (post-gastric surgery, gastroparesis, diabetes) and are responsive to enzymatic dissolution, whereas trichobezoars are not.
Option 3: This describes a pharmacobezoar, which is composed of inspissated medication residue—a different bezoar type entirely. PPI therapy is not the management for any bezoar type; surgical or endoscopic removal is the standard.
High-YieldNEET PG
Trichobezoars (hair) ≠ phytobezoars (plants); trichobezoars never dissolve; large trichobezoars with small-bowel extension (Rapunzel) require surgery.
Schwartz Principles of Surgery 11e; Naik et al. Rapunzel Review
Practice similar questions
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.
