1. Service de chirurgie digestive et endocrinienne, CHU Hassan II Fès
OCCLUSION INTESTINALE AIGUE PAR UN ÉNORME TRICHOBÉZOARD A TRIPLE LOCALISATION GASTRIQUE, JÉJUNALE ET ILÉALE : QUELLE CONDUITE A TENIR ?
occlusion caused by an enormous trichobezoar with a triple gastric, jejunal and ileal localization: what action to take?
Auteurs: AHMED ZERHOUNI, K.AZIZ, A, ISSAOUI A,MAROUNI, A.BELHAJ, I.DANDAKOY, I.TOUGHRAI, S.AIT LAALIM, H. EL BOUHADOUTI, B.BENJJELOUN, O.MOUAQUIT, A OUSSADDEN,
K MAZAZ, K AIT TALEB, K.IBNMAJDOUB
Service de chirurgie digestive et endocrinienne, CHU Hassan II Fès
Congrès national de chirurgie 2018

2. Introduction
Trichobezoar is a rare affection caused by presence of hair in the digestive tract, most often asymptomatic, with complications that may have begun the vital prognosis. Several topographic forms have been described, such as isolated gastric trichobezoar or with an extension to the duodenum or intestine defined by Rapunzel's syndrome

3. Observation
A 19-year-old patient was admitted urgently for an occlusive syndrome with post prondial vomiting associated to alteration of the general stateand and weight loss. The clinical examination found a patient anxious, dehydrated, the abdomen Examination revealed an epigastric mass. The abdominal tomography showed a large formation occupying the stomach until the 1st duodenal portion. This formation is hypodense compared to the gastric contents, heterogeneous, with presence of a distention arriving at 4.5 cm upstream of a 2nd intra luminal formation having the same characteristics of the gastric mass. Median laparotomy was performed in the emergency room. showing purulent effusion caused by perforation ileal, a gastrotomy of a few centimeters allowed the extraction of a large trichobezoard occupying the entire stomach after fragmentation and weighing about 3 kg.

4. gastrotomy for trichobezard evacuation

5. Enormous trichobezoar

6. DISCUSSION
The trichobezoard is a solid mass, formed of hair, suffering from trichotillomania. Its location is mainly gastric with, in some cases, a duodenal or proximal jejunal extension defining the Rapunzel syndrome. More rarely, there may be a double localization, both gastric and intestinal Diagnosis is based on esophagostroduodenal fibroscopy, It allows the visualization of tangled hair, pathognomonic of the trichobézoard. It can, sometimes, have a therapeutic interest by allowing the endoscopic extraction of small trichobezoids. CT with opacification of the digestive tract is of less interest in the diagnosis of gastric trichobezoard. However, CT remains prominent in the preoperative diagnosis of small bowel occlusions associated with a trichobezard with good sensitivity and specificity. The treatment is based on chemical fragmentation if this is possible and more often on surgery.

7. Conclusion 
Trichobezoards are rare. Although their diagnosis is easily made by upper gastrointestinal fibroscopy, a preoperative radiological examination based essentially on CT is necessary to demonstrate other intestinal localizations, thus facilitating their therapeutic management. .