Tangled

A 4-year-old girl presented with 1-year history of fatigue, early satiety, intermittent vomiting, alopecia, pallor, and weight loss without changes in bowel habits or overt gastrointestinal bleeding. Examination revealed thin hair, pale conjunctivae, and mucous membranes. Tachycardia and a systolic flow murmur (grade II/VI) were present. Abdomen was nontender, distended, and tympanitic, with hyperactive bowel sounds and a palpable mass in her left upper quadrant. Initial labs revealed iron deficiency anemia (hemoglobin 3.3 g/dL, mean corpuscular volume 48 FL, platelets 515000, ferritin 1.6 ng/mL) and hypoalbuminemia 2.9 g/dL. She was transfused with packed red blood cells and parenteral iron. Abdomen computed tomography (Figure 1) revealed a large gastric bezoar extending into the duodenum and a localized air-filled out pouching of stomach wall abutting the surface of liver concerning for sealed perforation. There was no small bowel obstruction or free air. Upper endoscopy confirmed a large trichobezoar in the stomach. She underwent a laparotomy with longitudinal gastrostomy and removal of the large trichobezoar (Figure 2). Intraoperative inspection showed ulceration over the fundus/body with contained perforation into the liver (segments 2/3). The patient did well postoperatively and tolerated a regular diet prior to discharge. A