Huge gastric trichobezoar caused by involuntary nocturnal trichophagia and trichotillomania in a female adolescent

Untangling rapunzel syndrome: A unique presentation of gastric trichobezoar

INTRODUCTION AND IMPORTANCE

Rapunzel syndrome is a rare condition that results from trichotillomania (compulsive hair pulling) and trichophagia (hair eating), causing a trichobezoar (hairball) to form This syndrome typically affects young females with psychiatric conditions and presents with symptoms like chronic abdominal pain, nausea, vomiting, and malnutrition. The condition is often diagnosed late, leading to serious gastrointestinal complications.

CASE PRESENTATION

A 19-year-old female from a rural community presented with chronic abdominal pain, vomiting, and nutritional deficiencies, including scaly skin and koilonychia. Over time, her symptoms worsened, and she discovered a palpable abdominal mass. Clinical evaluation, including an upper gastrointestinal endoscopy, revealed a large trichobezoar extending from the lower esophagus to the pylorus. The patient had a history of pica and compulsive behaviors, suggesting psychiatric involvement.

CLINICAL DISCUSSION

The endoscopy revealed a 20 × 13.5 × 9 cm trichobezoar. After successful surgical removal, the patient's gastrointestinal symptoms improved. Post-operatively, she received nutritional support and was referred for psychiatric evaluation to manage trichotillomania and trichophagia, with the aim of preventing recurrence in a private practice setting.

CONCLUSION

This case highlights the need for early recognition of Rapunzel syndrome in patients with chronic gastrointestinal symptoms and nutritional deficiencies. A multidisciplinary approach is essential for effective management and preventing recurrence.

A rare cause of intestinal obstruction in children trichobezoar: How to diagnose?

BACKGROUND

Trichobezoar is a rare clinical condition in children, which is caused by the accumulation of swallowed hair mass in the digestive tract. This condition is most common in young women with psychiatric histories who suffer from trichotillomania (TTM), where they have an irresistible urge to pull out their hair. Diagnosis and treatment of this pathology, which is already extremely rare, and its variable clinical presentations are challenging. The aim of this study was to increase awareness of trichobezoar in the differential diagnosis of signs of intestinal obstruction in children and to evaluate the diagnosis and management of this rare pathology.

METHODS

The clinical data of six patients who were treated for trichobezoars in the pediatric surgery department of our hospital between 2009 and 2022 were retrospectively analyzed.

RESULTS

Six female patients were treated with the diagnosis of trichobezoar during this period. Patients were diagnosed with the help of anamnesis, physical examination, abdominal ultrasonography (USG), and finally, endoscopy. USG can predict the intestinal wall infiltration and the tail extended to the duodenum through pylorus in the series. All patients were evaluated with contrast-enhanced abdominal radiography. Five surgical interventions were performed in four of the cases. In a case who underwent surgery twice, the distal intestinal satellite bezoar was not noticed in the first operation. Two patients were diagnosed to have trichobezoar, but surgery was not required. These patients were younger and had early-onset TTM (before 10 years old). The patients were followed for an average of 10.8 years and no recurrence was detected.

CONCLUSION

Trichobezoar is a rare cause of intestinal obstruction in children with fatal complications when diagnosed late. Failure to follow an algorithm for the management of the disease causes difficulties in the diagnosis and treatment. Especially in pa-tients with a known psychiatric history, whole abdominal USG and laparoscopy performed with awareness can prevent unnecessary examinations.