GASTRIC TRICHOBEZOAR - an ultrasound diagnosis

GASTRIC TRICHOBEZOAR - An ultrasound diagnosis

BEZOAR- accumulation of undigested injested material within GIT. Gastric trichobezoar is formed by accumulation of injested hairs in stomach . It is hair ball mass usually take shape of stomach. It is seen commonly in mentally subnormal females who used to injest their own hairs.  Rapunzel syndrome is same condition in which a long tail like extension of bezoar noted reaching in small bowel causing its obstruction. Other types of bezoars are - phytobezoar ( formed by undigested food materials) ,  pharmacobezoar ( formed by drugs) , lactobezoar ( by milk products) .

CASE DETAILS
A  12 yr female child with pain & lumpish feel upper abdomen, occasional vomiting & loosing weight.
She was slightly mentally subnormal . On clinical examination upper abdominal lump was seen . Routine lab tests were noncontributory .
AT USG
A large complex mass was noted in upper abdomen , seen as a huge echodensity  in the region of stomach . The mass was filling & occupying entire stomach lumen with few visible thick gastric rugae . The mass was so large to cast a huge semilunar or crescentic echodensity with distal shadowing obscuring underlying details. No any other thing was seen except a huge echodense structure , that was traced in entire gastric cavity [ Fig 1-2] . Rest of the abdominal findings were normal on ultrasound . On the basis of sonographic findings a diagnosis of gastric trichobezoar was made , which was confirmed at surgery  [ Fig - ].

Fig 1- A midline sagittal US scan upper abomen shows part of left lobe liver , thick stomach rugae & a large semilunar echodensity [arrows ] filling entire stomach cavity

Fig 2 - Epigastric US scan shows a huge echodensity [ gastric bezoar ]  with distal shadowing

Fig 3- per operative images shows mass ( trichobezoar) distending  the stomach , & during its removal 

Fig 4- Post operative gross specimen (trichobezoar taken shape of stomach)


PS 1] The case study in intended for radiologists & sonologists for academic  purpose
     2 ] I expresss my sincere thanks to Dr Gaurav Bahety , M . Ch [pediatric surgery], Bhilwara -Rajasthan for operative details

ULTRASOUND DIAGNOSIS OF SOLITARY SUBLINGUAL THYROID

A 10y boy diagnosed clinically & hormonally as hypothyroidism was evaluated with neck ultrasound. There was absence of normal thyroid in its infra laryngeal location . A well defined oval coarse hyperechoic spongiform nodular lesion noted in sublingual region midline supra hyoid location separate from both sublingual salivary glands . The lesion showed rim & internal vascularity on color doppler. No internal calcifications seen. In view of the nodule being in the track route of thyro-glossal duct, & absent normal thyroid in its location , a possible diagnosis of solitary sublingual thyroid was made ( Fig 1-4 ) . In vew of it's echo texture nodular spongiform appearance it might be adenomatous transforming . A thyroid isotope scan was suggested .

Fig 1- TS US neck scan shows absent normal thyroid in infra laryngeal location 

Fig 2- Coronal submental US scan shows a well defined spongiform nodule s/o sublingual thyroid tissue

Fig 3- The same nodule in midline sagittal scan seen in supra hyoid location 

Fig 4- color doppler shows rim & internal vasculature 

PS - The case study is intended for radiologists for academic purposes only 

ULTRASOUND EVALUATION OF MUSCLE HERNIA

ULTRASOUND EVALUATION OF MUSCLE HERNIA

Most muscle hernias occur in the lower leg and affect the tibialis anterior muscle , and are attributed to occupational and sporting activities, trauma , chronic compartment syndrome, and weakness in the overlying fascia due to perforating vessels. It is seen  as a result of muscle protrusion through a defect in the muscle  fascia into the subcutaneous fat and eventually seen as  an overlying bulging soft-tissue mass , making slight contour hump. The adolescents or young adults are affected more. Clinically a swelling is  seen that usually enlarges when the affected muscle is contracted or the patient is in  standing or erect posture , and reduces when the muscle is relaxed .  Mostly muscle  hernias are asymptomatic and requires no treatment . Those with mild symptoms that may be relieved by support stockings. Patients with severe pain or cramps may require surgery.

At USG -  1 ] Focal thinning and slight elevation of the fascia.

                2] Focal fascial defect with protrusion or bulge  of muscle fibres through the defect  when the muscle                     is contracted , and making a contour hump. [ fig 1,2] 

               3] Prominent arterial pulsation on color or power Doppler - support the theory that muscle herniation                        occurs at sites of weakness in which vessels penetrate the fascia [ fig 3] 

                                          Fig 1 - A 20 yrs young boy presented with a small swelling at mid part of right anterolateral leg , which becomes conspicuous & painful on exercise or on continuous walking .  Long US scan shows focal bulge in tibialis anterior muscle [ arrows] on muscle contraction or on standing 

                                           

                                          Fig 2 - Both LS & TS ultrasound scans of the same case  , shows a small focal defect in the Fascia of tibialis  anterior muscle [ arrow in TS scan ]  with focal muscle fibres bulge or contour hump [ arrow in LS scan ]

                              

                                            Fig 3 - TS & LS ultrasound with color doppler scans shows a prominent vessel , likely perforating artery , at the site of fascial defect & muscle bulge or hernia  

Most muscle hernias do not require any  treatment [  or requires just reassurance] , but some painful cases may needs surgery. Importantly ultrasound is very helpful in apprehensive patients to exclude muscle tears and tumors . 

PS – This presentation is intended for academic purpose esp. for medical professionals & radiologists

Ref - American Journal of Roentgenology. 2003;180: 395-399

      [Read More: http://www.ajronline.org/doi/full/10.2214/ajr.180.2.1800395]