Black Stomach: A Rare Case of Gastric Trichobezoar

Introduction: Bezoars are collections of partially digested or undigested material within the gastrointestinal (GI) tract. It is responsible for 0.4%-4% of cases of mechanical intestinal obstruction and may be associated with other complications. Herein we report a case complicated by diffuse GI necrosis. Case Description/Methods: 47-year-old female with a history of type 2 diabetes mellitus (DM), and chronic pancreatitis admitted for abdominal pain. Positive history of trichophagia.Physical examination elicited epigastric tenderness. Laboratory testing showed elevated WBC and HbA1c: 8.4%. CT imaging showed chronic calcific pancreatitis as well as a distended stomach filled with bubbly material, consistent with bezoar. Esophagogastroduodenoscopy (EGD) revealed esophagitis, and diffuse necrosis involving 75% of the stomach with well demarcated margins and a pylorus ulcer extending to the duodenal bulb (figure 1). Endoscopic breakdown was done and diet was modified. Biopsy report showed duodenal mucosa with Brunner gland hyperplasia and ulcerated gastric mucosa with chronic active gastritis and abundant granulation tissue. Follow up EGD showed resolution. Discussion: Bezoars are classified based on the content of their constituent material (table 1). Predisposing factors for bezoar formation include poor mastication, impaired digestion, delayed gastric emptying, or altered anatomy. In our patient, risk factors included DM and chronic pancreatitis.Bezoars may remain asymptomatic but over time could cause obstruction. Specific complications may be related to the content of the bezoar. For example, release of active ingredients in pharmacobezoars may result in drug-specific local and systemic complications. Local complications from bezoars include ulceration, bleeding, bowel obstruction, necrosis, and/or perforation. Prompt diagnosis and appropriate treatment is therefore vital. Investigations include radiography, barium studies, ultrasonography, CT imaging, and endoscopy. CT scans are particularly reliable and can identify the presence of any additional bezoars along the length of the GI tract. However, endoscopy remains a choice option given its benefit of direct visualization, tissue sampling, and possible therapeutic application. Goals of care include removal (via dissolution, endoscopy, or surgery) and prevention of recurrence (with dietary modification, risk factor avoidance, and motility problem correction). Removal strategy decisions are often made based on type, size, and location of the bezoar.Figure 1:: A: Abdominal computed tomography (CT) image showing debris-filled stomach B: Endoscopy image showing area of diffuse necrosis within the stomach C: Image of repeat endoscopy showing resolution.Table 1.: Summary of bezoar types and treatment options.