Images in clinical medicine. Trichobezoars

Small-Bowel Obstruction Secondary to Ileal Trichobezoar in a Patient with Rapunzel Syndrome

Bezoars are conglomerations of undigested foreign material retained in the gastrointestinal tract. Trichobezoar is a compact conglomeration of swallowed hair and constitutes less than 6% of all bezoars. Their most frequent location is in the stomach but they may extend through the pylorus into the small bowel. This condition is known as Rapunzel syndrome. Many patients may remain asymptomatic or present a mild form of the disease characterized by abdominal pain, early satiety, nausea, and vomiting. Complications may manifest as gastric outlet obstruction or bleeding, and intestinal obstruction. A 15-year-old female patient presented with clinical findings of intestinal obstruction. The patient suffered from depressive and anxiety disorders and trichotillomania, although trichophagy could not be assured. Alopecia circumscripta and irregular hair length on the scalp were identified. A computed tomography (CT) scan showed two images highly suggestive of trichobezoars, one in the stomach and the second one causing obstruction at the ileocecal valve. At laparotomy, both a mobile gastric trichobezoar with a tail extending to the duodenum and a trichobezoar causing obstruction at the ileocecal valve were removed. The postoperative course was uneventful. The passage of a detached trichobezoar fragment in a patient with Rapunzel syndrome may cause intestinal obstruction. CT is the preferred image modality for the evaluation of suspected trichobezoars in order to characterize their size and locations, the presence and level of obstruction, and complications such as ischemia or perforation. A case of small-bowel obstruction secondary to ileal trichobezoar in a patient with Rapunzel syndrome is herein reported.

Gastric trichobezoar: an enduring intrigue

Trichobezoar is a rare condition that may pose a diagnostic challenge. Patients with this condition often have an underlying psychiatric illness, and history may not be easily forthcoming. The condition should be entertained especially in young females. Delay in diagnosis may lead to futile complications. We report a classic case of trichobezoar in terms of patient profile, presentation, and investigative findings.

Trichotillomania +/- trichobezoar: revisited

Trichotillomania is an intriguing psychosomatic entity in which there is an irresistible desire to pull out the hair from the scalp, eyelashes, eyebrows and other parts of the body. The process results in an instant release of tension, a sense of relief and security. However, non-scaring alopecia is its clinical presentation. The development of trichobezoar following ingestion of the pulled hair is its salient complication in a few cases. Subsequently, it may cause symptoms pertaining to the gastrointestinal tract culminating in intestinal obstruction, perforation, pancreatitis and obstructive jaundice. The Rapunzel syndrome (trichobezoar) may occur when gastrointestinal obstruction is produced by a rare manifestation of a trichobezoar with a long tail that extends to or beyond the ileocecal valve. In most cases in children, trichotillomania +/- trichobezoar is a habit disorder and thus has a better prognosis. However, in adults the psychopathology is usually deeper and thus entails a poor prognosis. The diagnosis is made after taking a thorough history, noting the clinical features and evaluating a hair-root examination, where telogen hair is (almost) completely lacking, which distinguish trichotillomania from other hair disorders. Treatment modalities vary in childhood and adult varieties. Apart from psychotherapy, the drug treatment involves several agents including selective serotonin reuptake inhibitors (SSRIs) and domipramine. Trichobezoar/Rapunzel syndrome requires surgical intervention.

Le trichobézoard gastrique : une observation

The gastric trichobezoar is a rare disease in which diagnosis is easy in case of evocative context. Its treatment is not standardized. The authors report the case of a 9 year old girl, known to have trichophagy, presenting with a large epigastric mass. Upper endoscopy made the diagnosis of a trichobezoar. Surgical extraction was performed through gastrotomy, without complications. Psychiatric follow-up was recommended.

Bezoars in the stomach and small bowel--CT appearance

AIM

The aim of this study was to present the computed tomography (CT) appearance of trichobezoars, phytobezoars and other unusual ingested material.

MATERIALS AND METHODS

Seven patients diagnosed on CT with bezoars in the stomach or small intestine were reviewed with special attention on the characteristics of the intraluminal mass and the presence of proximal dilatation.

RESULTS

There were six women and one man aged 14-81 years. CT was performed because of abdominal pain and a palpable abdominal mass. In none of the cases was the diagnosis suspected clinically. Four patients had a trichobezoar occupying the entire lumen of the stomach. It appeared as a concentric inhomogeneous mass with entrapped air, surrounded by contrast material. In the other three patients the bezoar was confined to the small intestine and was composed respectively of vegetable fibres, ingested toilet paper and an olive stone. The first two had a mottled appearance whereas the last one was small, spherical and well defined. Variable proximal dilatation of the small bowel was present in all three.

CONCLUSION

With the increased use of CT in the evaluation of patients with non-specific abdominal pain, it is important to recognize the CT appearance of bezoars, as this diagnosis is often not suspected clinically.