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INTRODUCTION: Bezoars are concretions of foreign indigestible material accumulating in the gastrointestinal tract leading to intraluminal mass formation that impairs the gastrointestinal motility and can lead to gastric obstruction of the small or the large bowel. There are different types of bezoars, named according to the material they are made of. These include phytobezoar, lactobezoar, pharmacobezoar, trichobezoar, and polybezoar. Trichobezoars (hair ball) are usually located in the stomach but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome). CASE PRESENTATION: Herein, we report a case of a young adult female known to have a long-standing trichophagia who presented with gastric outlet obstruction due to a large trichobezoar. Endoscopy revealed a large and hard gastric trichobezoar not amenable to endoscopic retrieval leading to surgical extraction as a last resort. DISCUSSION: They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. Trichobezoar can be treated either surgically by laparotomy/laparoscopy or by endoscopic intervention. CONCLUSION: Treatment should be coupled to psychiatric evaluation and therapy to prevent recurrence.
RESUMO
The diagnostic rationale for patients with chest pain requires an electrocardiogram (ECG) often limited by low pretest values and widely variable post-test values. We assess the value of ECG ordered and interpreted by internal medicine junior medical officers in our emergency department (ED). Participants enrolled in this study included patients who presented to the ED for chest pain between June and October 2014. Seventeen leads ECG were performed systematically when an ECG was judged required by the medical officer in charge and interpreted by a blinded medical officer and ED attending. Ultrasensitive troponin T (usTrop T) and creatinine were also withdrawn. Junior medical officers ordered ECG more commonly for atypical chest pain (57 vs 43%, P = 0.049). Univariate and multivariate analysis did not demonstrate a statistically discordant diagnosis between the medical officer and the attending throughout the study period and between the different rotations. We demonstrated 97% sensitivity, 95% specificity, 92% positive predictive value, 98% negative predictive value and 96% accuracy. Our junior medical officers demonstrated an overall high proficiency in the clinical and bedside setting. This finding reinforces our ECG education in the undergraduate curriculum, highlights the importance of the intensive recapitulation sessions undergone at the beginning of the training programme and our daily internal medicine staff discussions rarely performed in other EDs as reported with our experience.
