Case Report
An Unusual Case of an Abdominal Mass in a 3 Year Old
Charlene Antony, MSc, MD Candidate, Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario
Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
Andrew Latchman, MD, FRCPC, Division of General Pediatrics, McMaster Children’s Hospital
Assistant Professor, Department of Medicine, McMaster University, Hamilton, Ontario
Mark Walton, MD, FRCSC, Division of Pediatric General Surgery, McMaster Children’s Hospital, Hamilton, Ontario
Assistant Dean, Post Graduate Medical Education, McMaster University, Hamilton, Ontario
Abstract
An abdominal mass in a young child is a significant concern that requires urgent assessment. The
differential diagnosis is often initially focused on
malignancies including Wilm’s tumor, hepatoblastoma, neuroblastoma, and lymphoma. We present
an unusual case of an abdominal mass in a 3 year
old boy who clinically presented with post-prandial
emesis and increasing fatigue. An upper GI series
confirmed the presence of a gastric bezoar, which
upon surgical removal was found to be composed of
human hair and carpet fabric. His laboratory studies had revealed a severe iron-deficiency anemia,
which required a transfusion prior to surgery. In addition, the child also presented with associated fine
motor and language delays. This case highlights the
importance of primary prevention of iron deficiency amongst infants and toddlers.
Introduction
I
ron deficiency (ID) is the single most common nutritional deficiency globally, with resulting anemia affecting
approximately 750 million children worldwide.1 In developed countries, risk factors associated with iron deficiency
anemia (IDA) include high consumption of cow’s milk before 12 months of age, prolonged exclusive breastfeeding,
and chronic infection.1
Corresponding Author:
Charlene Antony
University of Toronto
Faculty of Medicine
1 King’s College Circle
Toronto, Ontario
Email: [email protected]
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Pica is often an associated symptom of IDA, occurring in
up to 58% of these patients.2 Ingested substances typically include ice chips, clay, and starch; however, we present a case of
chronic hair consumption that resulted in the formation of a
trichobezoar.
Trichobezoars are concretions of mostly hair, which accumulate in the gastrointestinal tract. They are often associated
with underlying psychiatric disorders, and most commonly
present in the female adolescent population.3 Rapunzel syndrome is an unusual and rare form of trichobezoar extending into the small intestine, which can be fatal as it can cause
abdominal obstruction, which can progress to perforation.
Here, we present a rare case of Rapunzel syndrome within a 3
year old boy secondary to pica associated with IDA.
CASE
A 3 year old boy, presented to the ER with a four week
history of post-prandial emesis and progressive fatigue. Although he had minimal tolerance for solids, he was able to
consume 27-36 ounces (800-1064 mL) of homogenized milk
daily. He also had a nine month history of ingesting hair and
fabric off the carpet but had maintained regular bowel moments. The child was born full-term and had been breastfed
up to 8 months, at which point he was transitioned to homogenized cow’s milk. Developmentally, he demonstrated delays
in fine motor skills such as an inability to take off his shoes or
socks. In addition, he had gross delays in language development with only 10 words in his vocabulary up to this point,
and would communicate largely through pointing. All other
developmental parameters were within normal limits.
His physical examination was significant for a non-tender
palpable mass in the epigastric area. An abdominal x-ray revealed an increased opacity within the stomach, which was
later confirmed with an upper GI series to likely be a bezoar.
Laboratory investigations revealed a severe hypochromic microcytic anemia with a hemoglobin level of 63 g/L and mean
corpuscular volume of 52.4 as well as low ferritin levels. He was
subsequently transfused and a gastrostomy was performed,
which revealed a bezoar weighing 412 g, that was largely composed of hair and coloured yarn (Figure 1). The trichobe-
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Case Report
An Unusual Case of an Abdominal Mass in a 3 Year Old
zoar had conformed to the entire shape of the stomach and
had a tail that extended into the proximal duodenum, as seen
in Rapunzel syndrome. The patient was subsequently started
on an iron supplement, and counseled on iron-rich foods as
well as restricted on milk intake. Active measures to aid in his
developmental progress were also undertaken.
Figure 1. A large trichobezoar (15 cm x 8 cm x 5 cm) casting the shape
of the stomach and the proximal duodenum is removed via gastrostomy.
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Discussion
Iron is a vital micronutrient that is used by virtually every cell and organ system in the body. As a consequence, ID
leads to anemia but also has profound effects on cognitive
and behavioural performance, physical growth and immune
function, and can even result in death.4 Recent studies have
also shown that children who have had a stroke are ten times
more likely to be iron deficient.5
Of great concern, however, is the fact that several studies
have demonstrated a consequence of cognitive and motor delay in infants and children with IDA. Decreased iron stores
in the brain may hinder the synthesis, functioning and degradation of neurotransmitters such as serotonin, noradrenaline, and dopamine, thus impacting the overall development
of these children.6 Extensive reviews exploring the effect of
IDA have concluded that these children had poorer cognitive scores, delays in acquisition of fine motor skills and an
overall lower scholastic achievement.7,8,9 However, possible
confounding factors such as low socioeconomic status, lack of
stimulation in the home, low maternal IQ, low birth weight
and undernutrition prevent causal inferences from being
made.8
Unfortunately, the efficacy of treatment for IDA is still
under much debate, as a large number of randomized controlled trials have shown little convincing evidence that elemental iron can improve the psychomotor development
scores of IDA children under or over the age of two.9 This
indicates, that the developmental consequences of IDA may
remain largely irreversible or are compounded with other factors associated with the condition.
Thus, primary prevention becomes paramount. The avoidance of the sequelae of ID begins in utero as the mother’s intake of dietary iron affects the iron stores present in the baby
at birth. As full-term infants, iron stores typically last from
ages four to six months after which, the introduction of ironfortified cereals, including foods enriched with vitamin C to
improve iron absorption, are strongly encouraged. Pre-term
and low-birth weight infants have even lower stores of iron
and are at an even greater risk of developing IDA sooner.10
Moreover, it is important to counsel families on avoiding homogenized milk for a baby younger than 12 months old, as it
impairs iron absorption.1,10 Limitations on daily milk intake of
less than 24 ounces (710 mL) should also be advised.11
Our patient had been introduced to homogenized milk at
eight months of age. This was further compounded by a large
intake of milk and a corresponding decrease in his intake of
iron-containing solids. As his iron stores became deplete and
resulted in anemia, his associated pica for human hair and
yarn resulted in intestinal obstruction. As a consequence, he
required a blood transfusion to raise his hemoglobin level
and an operation to remove the gastric bezoar. He also had
fine motor and language delays, which may be secondary to
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Case Report
An Unusual Case of an Abdominal Mass in a 3 Year Old
the IDA. This case serves to highlight the importance of dietary screening in the anticipatory guidance for infants and
toddlers with the goal of prevention of IDA and its many complications.
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