Trichobezoar is an intraluminal mass formed from the accumulation of undigested hair. It is a rare condition that is typically seen in young females with trichophagia and trichotillomania. When not recognized, it may present with complications such as obstruction, ulceration and in some rare cases, perforation. While most trichobezoar perforations are located in the stomach, however, duodenal perforation has not been reported before. We report a case of a 13-year-old girl who presented to the emergency with signs and symptoms of peritonitis and perforated viscus. Radiological investigation revealed a large heterogenous intraluminal mass with mottled gas pattern suspicious of bezoar. Oral contrast was seen tracking from the gastric pylorus into the peritoneum suggestive of a perforation. The girl was brought to theatre for emergency laparotomy and a trichobezoar was found extending from the stomach down to the level of D1. There is a perforation in D1 on its antero-superior surface measuring 1×1 cm. The bezoar was removed via a gastrostomy and the perforation was primarily repaired and patched with omentum. Post operatively, her recovery was complicated with wound breakdown and was subsequently discharged after 1.5 months of hospitalization with outpatient referral for psychiatry consults.

Pyogenic liver abscess (PLA) is a condition in which there is pus accumulation in the liver. It usually develops in the context of portal pyemia, through hematogenous seeding as well as via biliary disease. PLA is a rare, but important complication following biliary instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP). We report a case of a 44-year-old man who initially presented with clinical features of ascending cholangitis. Laboratory investigations revealed leukocytosis as well as hyperbilirubinemia. Diagnosis of choledocholithiasis was then confirmed with an ultrasound examination, showing a 1×1 cm stone in the common bile duct. ERCP was performed and achieved stone clearance. However, the patient returned 1 month later with similar symptoms of right upper quadrant pain, fever and jaundice. Suspecting recurrent choledocholithiasis, an emergency ERCP was performed and showed pooling of radio-opaque contrast in the extra-biliary space. There were also multiple CBD stones seen. An urgent CT Abdomen was done and revealed multiple liver abscesses in bilateral liver lobes, with the largest measuring 4.5x5.9x2.1cm. The patient was treated conservatively with Augmentin and repeat ultrasound at 4 weeks interval showed no residual liver abscess.

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