Intended for healthcare professionals

Endgames Case Review

Gastric perforation in a 16 year old girl

BMJ 2017; 357 doi: (Published 03 May 2017) Cite this as: BMJ 2017;357:j1859
  1. Adam Nunn, core surgical trainee1,
  2. Nina Jahn, clinical psychologist2,
  3. James Hewes, consultant upper gastrointestinal surgeon3,
  4. Christopher Wong, consultant upper gastrointestinal surgeon3
  1. 1Southmead Hospital, Bristol
  2. 2Munro Centre, London
  3. 3Southmead Hospital, Bristol
  1. Correspondence to A Nunn adam.nunn{at}

A 16 year old girl presented with sudden onset severe central abdominal and left shoulder pain. She had a history of intermittent generalised abdominal pain associated with early satiety and nausea after eating over the preceding year. On assessment, she was tachycardic at 120 beats/min and had a firm, tender mass in the epigastrium. Blood tests revealed a normocytic anaemia (haemoglobin 84 g/L, normal range 12-16) and a neutrophil count of 15×109 /L (normal range 1.8-8). A plain chest radiograph showed substantial air under the diaphragm, and computed tomography (CT) imaging identified the presence of a large hypodense, heterogeneous mass that almost completely filled the stomach, with leakage of oral contrast into the intra-abdominal space (fig 1). On direct questioning, the patient admitted to a tendency to chew her hair, but claimed she had refrained from this for nearly a year preceding her current presentation.

Fig 1 (A) Erect chest radiograph. (B) Computed tomography image (coronal view) of abdomen and pelvis with oral contrast


  • 1. What is the cause of this patient’s presentation?

  • 2. What is the acute management of this condition?

  • 3. How should the psychological aspects of the case be managed?


1. What is the cause of this patient’s presentation?

Short answer

Perforation of the stomach secondary to a giant trichobezoar (fig 2).

Fig 2 (A) Erect chest radiograph. (1) Free air under diaphragm. (B) CT coronal view of abdomen and pelvis with oral contrast. (2) Oral contrast seen outside stomach (indicating perforation); (3) Locules of free air …

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