DeVivo DC, Haymond M, Obert K et al. Defective activation of the pyruvate dehydrogenase complex in subacute necrotizing encephalomyelopathy (Leigh's.
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study. Radiology 1987, 162: 115-118. 15. Hall K, G a r d n e r - M e d w i n D. CT scan appearances in Leigh's disease (subacute necrotizing encephalomyetopa thy). Neuroradiology 1978, 16: 48-50. 16. Campistol J, Fernandez-Alvarez E, Cisi V.CT scan appearance in subacute necrotizing encephalomyelopathy.Dev Med Child Neurol 1984, 26: 519-522.
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17. Mclandless DN, Hodgkin WE. Subacute necrotising encephalomyelopothy (Leigh's
disease), editorial. Pediatrics 1977, 60: 935936. 18. DeVivo DC, Haymond M, Obert K et al. Defective activation of the pyruvate dehydrogenase complex in subacute necrotizing encephalomyelopathy (Leigh's disease). Ann Neurol 1979, 6: 483-494.
Gastric Perforation Secondary to Recurrent Trichobezoar J i l e d a r , G u r p r e e t S i n g h a n d S.K. Mitra
Department of Paediatric Surgery, PGIMER, Chandigarh Abstract. A rare case of 1O-year-old female child with recurrent trichobezoar stomach is reported, which presented with features of gastric outlet obstruction with perforation.
Key words : Recurrent trichobezoar; Gastric perforation; CASE REPORT
A 10-year-old female child p r e s e n t e d in paediatric emergency with a 2 week history of pain u p p e r a b d o m e n (dull and continuous type) accompanied with recurrent non-bilious v o m i t i n g and low grade intermittent fever. She also h a d mild u p p e r a b d o m i n a l distension for the last two days. She had been o p e r a t e d earlier for trichobezoar stomach at the age of six years yet she continued w i t h the habit of eating her o w n hair. General physical examination was nonc o n t r i b u t o r y except for mild d e h y d r a t i o n and pallor. A firm to hard nonmobile lump was p a l p a b l e e x t e n d i n g from left Reprint requests: Dr. Gurpreet Singh, Astt. Prof, Pediatric Surgery 2192, Sector 15-C, Chandigarh.
h y p o c h o n d r i a c r e g i o n to the l e v e l of umbilicus. G u a r d i n g a r d r i g i d i t y were present, but m a i n l y localised to the left upper abdomen. Alongwith that there was t h e s c a r of p r e v i o u s s u r g e r y ( r i g h t p a r a m e d i a n incision). Plain X-ray of the a b d o m e n revealed free air u n d e r the left d o m e of diaphragm. Ultrasound s h o w e d t h e p r e s e n c e of h y p e r e c h o i c m a s s occupying whole of the stomach. A f t e r c o r r e c t i n g d e h y d r a t i o n , an exploratory l a p a r o t o m y was carried out (via t h e p r e v i o u s r i g h t p a r a m e d i a n incision). A 5 cm tA4 cm sized perforation was seen in the anterior gastric wall, close to the lesser curvature - nearly in the midportion of stomach. A trichobezoar was s e e n w i t h i n t h e l u m e n of s t o m a c h ,
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e x t e n d i n g w e l l i n t o t h e u p p e r p a r t of jejunum (Fig. 1). Alongwith that there were m u l t i p l e p o c k e t s of p u s , a n d s m a l l intestinal inter-loop adhesions.
b u t has been postulated to b e related to pica, and is considered to be analogous to the biting of nails2 Most of these patients are psychologically stable; only 9% having demonstrable mental disturbance. ~ Trichophagy has also been referred to as being a personality maladjustment. Trichobezoars are usually encountered in y o u n g females, with more than 80% occurring below 30 years of age. Once hair, or b u n c h e s of hair are swallowed, they are u s u a l l y retained (or attached) in the folds of g a s t r i c m u c o s a . This is d u e to insufficient friction surface necessary for forward propulsion by peristalsis; smoothness of the hair is a s u p p l e m e n t a r y factor in this regard. The ingested hair a l w a y s turns black (irrespective of the original colour) d u e to the denaturation of proteins in a highly acidic m e d i u m . 3 Gastric trichobezoars usually present as a large firm mass in the epigastrium which m a y be accompanied b y epigastric pain, nausea, vomiting, weight loss, anaemia, diarrhea or constipation. Occassionally these m a y present with complications like h a e m a t e m e s i s , g a s t r i c u l c e r a t i o n and perforation. Amongst these, perforation is t h e l e a s t c o m m o n l y e n c o u n t e r e d c o m p l i c a t i o n . 4 O n l y i s o l a t e d c a s e s of trichobezoar leading to gastric perforation are r e p o r t e d , s~6 H o w e v e r , i n c i d e n c e of gastric perforation with lactobezoar and p h y t o b e z o a r is quite high. 3'7 This could be d u e to the h y g r o s c o p i c n a t u r e of the retained products inside the stomach. In this case the gastric perforation could have b e e n d u e to e i t h e r g a s t r i c o u t l e t obstruction, or secondary to erosion by the trichobezoar Interestingly, there are a few reports of t r i c h o b e z o a r s being f o u n d in prim0tes
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Fig. 1. Extracted specimen of trichobezoar A g a s t r o t o m y w a s d o n e b y extending the i n c i s i o n f r o m t h e l o w e r e d g e of perforation, a n d t r i c h o b e z o a r e x t r a c t e d enmasse. The e d g e s of p e r f o r a t i o n w e r e freshened and g a s t r o t o m y closed in t w o layers over an omental patch. "Ihe abscess cavities were d r a i n e d and the adhesions l y s e d . The c h i l d m a d e an u n e v e n t f u l r e c o v e r y a n d w a s r e f e r r e d to t h e psychiatrists for further m a n a g e m e n t . DISCUSSION Trichobezoar results from an a d v e r t a n t or inadvertant s w a l l o w i n g of hair. Majority of the patients s w a l l o w their o w n hair. It is unclear w h y this p e r v e r t e d habit occurs,
