Trichotillomania and trichophagia leading to trichobezoar

When the Gut Tells a Story: Bezoars in a Neglected Autistic Child

This case study delves into the unique presentation of bezoars in a 14-year-old autistic female who exhibited chronic diarrhea and abdominal pain. While trichobezoars, masses formed from ingested hair, are rare, they are predominantly seen in young females and are associated with psychiatric conditions. Through rigorous diagnostic procedures, including a computed tomography imaging of the abdomen and pelvis (CTAP) scan, fecal impaction, and multiple bezoars, including hair and non-biological items, were identified. The background revealed significant neglect, emphasizing the importance of a comprehensive approach that integrates medical, surgical, and psychosocial care.

The Rapunzel syndrome: a hairy tale

BACKGROUND

Trichobezoars are a rare medical condition, often requiring a surgical approach and commonly associated with an underlying psychiatric disorder. The Rapunzel syndrome is a rare variant of trichobezoar in the stomach extending from the stomach into the small intestine causing a bowel obstruction.

CASE PRESENTATION

In this case report, the clinical presentation, diagnostic approach, and surgical removal of a large-size bezoar (Rapunzel syndrome) in a young and otherwise healthy female is described. Different surgical strategies are discussed. Psychiatric exploration gives an insight on development of trichophagia ultimately leading to the forming of the trichobezoar.

CONCLUSIONS

This brief report sheds light on the importance of the collective mind of a multidisciplinary team preventing a potentially fatal outcome.

Rapunzel Syndrome in a Teenage Girl: A Case Report

Trichobezoars are concretions of retained, undigested material, mostly hair or hair-like fibers in the stomach. Rapunzel syndrome is the condition when trichobezoars extend into the small bowel, leading to various complications including bowel obstruction, and perforation due to pressure necrosis. We present an interesting case of trichobezoar in a 15-year-old female patient, who presented with abdominal pain for one month duration. The exam was notable for a firm palpable mass in the epigastric area associated with localized tenderness and guarding. Contrast-enhanced CT of the abdomen showed a distended stomach with the bezoar, dilated duodenal loops, and clumping of proximal jejunal loops. Upper gastrointestinal endoscopy showed a trichobezoar extending from the oesophagogastric junction to the pylorus. Endoscopic removal of the trichobezoar was not successful.  An elective laparotomy was performed, during which the stomach, duodenum, and proximal jejunum were dilated. The trichobezoar, measuring 35 cm in length, extended from the body of the stomach to the proximal jejunum and caused jejunal perforation due to pressure necrosis. The trichobezoar was removed and primary closure of jejunal perforation with diversion gastrojejunostomy and jejunostomy was done. There were no postoperative complications. The patient followed up with psychiatry in the clinic after discharge, she was diagnosed with trichotillomania and started on fluoxetine, with improvement in her behavioral symptoms. In young female patients with nonspecific chronic abdomen pain and a palpable mass, trichobezoar should be considered in the differential diagnosis. Contrast-enhanced abdomen CT is the preferred imaging modality and removal of the trichobezoar with an appropriate endoscopic or surgical procedure is the treatment of choice. It is essential to diagnose and treat the underlying behavioral condition to prevent recurrent episodes.

Gastric trichobezoar in the absence of psychosocial stressors: a report of two cases

Abstract.

Patterned Trichoteiromania in Androgenetic Alopecia

Trichotillomania is the most frequent reported cause of self-inflicted hair disorders, within which are included trichoteiromania, trichotemnomania, and trichocryptomania, also known as trichorrexomania. These conditions are commonly described in the context of psychiatric disorders. Nevertheless, there exists reports in otherwise healthy patients that suffer a form of no cicatricial alopecia, such as alopecia areata. We communicate 3 cases of male androgenetic alopecia with patterned miniaturization that coexisted with trichoscopic findings of trichoteiromania. The presence of brush-like ends or broom hairs is a highly suggestive feature of this entity. To the best of our knowledge, this association was not previously reported in the medical literature. The possibility of self-induced hair loss should be kept in mind during every follow-up visit in all types of alopecia, remembering that hair loss itself is already a distressing condition.

Pica in end-stage chronic kidney disease: Literature review

Pica is an individual entity in the patient with chronic kidney disease (CKD), which phenomenon has not been widely studied despite the high reported prevalence. Moreover, pica complications (anemia, altered electrolytes, poor absorption of micro and macronutrients and malnutrition) could be exacerbated in CKD and limit the quality of renal replacement therapy. The intake of non-caloric and non-nutritional substances could be harmful and cause effects on satiety and metabolic / electrolyte imbalance and modify the biocompatibility of micronutrients, toxins and pathogens worsening health status. In daily practice, pica could be under-reported because patient's shame to recognize it, or fear that such behavior influences their treatment. Additionally, clinicians who not investigate the presence of pica or its complications contribute to the lack of information about the magnitude and relevance of this problem in CKD.

Endoscopic retrieval of gastric trichophytobezoar: Case report of a 12-year-old girl with trichophagia

RATIONALE

Trichophytobezoars, which are composed of hair and plant fibers, are usually located in the stomach. They are often associated with trichophagia and trichotillomania. The most commonly reported methods of trichophytobezoar treatment are open surgery and laparoscopic retrieval; there are few reports of endoscopic removal of trichophytobezoars.

PATIENT CONCERNS AND DIAGNOSES

Twelve-year-old girl presented with a 3-day history of increasing upper abdominal pain, anorexia, and postprandial emesis. She had a 3-year history of pulling out and eating her own hair. Endoscopic examination showed a large intragastric trichophytobezoar measuring 10.5 cm × 3.5 cm in size, with extension of a few hairs through the pylorus.

INTERVENTIONS AND OUTCOMES

The trichophytobezoar was packed with hair fibers and contained a hard core of mixed hair and vegetable fibers. After the core was cut, the trichophytobezoar was fragmented into pieces with the alternating use of a polypectomy snare and argon plasma coagulation. A small amount of hair and nondigestible food fibers was removed with grasping forceps during the initial procedure. The remaining hairball was loosened with biopsy forceps and was injected with sodium bicarbonate solution. The trichophytobezoar was removed completely at repeat endoscopy 5 days later. After 6 months of psychological intervention, the patient had no recurrence of trichophagia or trichophytobezoar.

LESSONS

Endoscopy with sodium bicarbonate injection is an effective and minimally invasive method of retrieving a gastric trichophytobezoar.

A rare case of small bowel obstruction due to primary trichobezoar

A trichobezoar is a mass of culminated hair within the gastrointestinal tract. Stomach is the common site of occurrence. Intestinal obstruction due to primary trichobezoar is extremely rare. Only few cases have been reported so far. We also present a case of 13-year-old girl having primary ileal trichobezoar causing intestinal obstruction.

Rapunzel syndrome: a comprehensive review of an unusual case of trichobezoar

An unusual form of bezoar extending from the stomach to the small intestine or beyond has been described as Rapunzel syndrome. Bezoars are concretions in the gastrointestinal tract that increase in size by continuous accumulation of non-absorbable food or fibers. Most bezoars in children are trichobezoars from swallowed hair from the head, dolls, or brushes. Trichobezoars typically cause abdominal pain and nausea, but can also present as an asymptomatic abdominal mass, progressing to abdominal obstruction and perforation. Trichobezoar with Rapunzel syndrome is an uncommon diagnosis in children with less than 40 cases reported. It is predominantly found in emotionally disturbed or mentally retarded youngsters. We present the youngest case of Rapunzel syndrome in the United States, a 5-year-old girl with mental retardation who presented with abdominal pain, vomiting and a non-tender abdominal mass.

Clinical characteristics of trichotillomania with trichophagia

OBJECTIVE

Little is known about trichophagia in individuals with trichotillomania. Although studies have mentioned the behavior, no previous studies have examined clinical correlates of trichophagia.

METHOD

We examined the clinical correlates of trichophagia in 68 subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, trichotillomania (85.3% females; mean age, 35.0 +/- 12.5). Comorbidity data were obtained with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Trichotillomania severity was assessed with the Psychiatric Institute Trichotillomania Scale and the Massachusetts General Hospital Hairpulling Scale. Social/occupational functioning was examined using the Sheehan Disability Scale. All variables were compared in trichotillomania subjects with and without trichophagia.

RESULTS

Of the 68 subjects with trichotillomania, 14 (20.6%; 95% confidence interval, 12.7%-31.6%) reported current trichophagia, and an additional 9 (13.2%) ate their hair or the root episodically. There were far more similarities than differences in trichotillomania subjects with current trichophagia and those without, although those with trichophagia were significantly more likely to be male (P = .013) and have more severe trichotillomania (according to the Massachusetts General Hospital Hairpulling Scale) (P = .010).

CONCLUSIONS

These preliminary results suggest that trichophagia is not uncommon in individuals with trichophagia. Subjects with and without trichophagia were similar in most domains that were examined.

Gastric bezoar in anorexia nervosa

OBJECTIVE

To report the case of a gastric bezoar in a patient with anorexia nervosa (AN).

METHOD

Case report of a bezoar of the stomach occurring in AN and a review of the literature relating to bezoars and AN from PubMed.

RESULTS

A 19 year-old female presented with a 2-year history of AN binge-purge subtype. After 7 days of complete adherence to diet and no purging in hospital, she complained of increased nausea. She vomited up a cylindrical mass that was sent for pathology. A literature search yielded only one report of a bezoar in AN.

DISCUSSION

Bezoars are agglomerations of food or foreign material in the intestine. They usually present with abdominal pain, intestinal obstruction, weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred method of diagnosis. Clinicians should consider the diagnosis of a bezoar in AN if there is concomitant pica, trichotillomania, or a change in gastrointestinal symptomatology.

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.

Large gastric trichobezoar in a normal healthy woman: case report and review of pertinent literature

This report presents a unique case of a gastric trichobezoar in a relatively healthy, young female with no history of psychological or psychiatric disorders. Furthermore, unlike previously reported cases, this patient had no history of gastric surgery. The mode of presentation and the difficulties in diagnosis are discussed. The different modalities of treatment, both surgical and nonsurgical, are evaluated and discussed. The diagnosis of a trichobezoar in a healthy patient requires a high index of suspicion, as it can present with nonspecific symptomatology. It should be included in the differential diagnosis of nonspecific abdominal pain.

Trichobézoard : à propos de 5 observations

Trichobezoars are made up of concretions of ingested hair and food. A history of occlusive syndrome in a context of trichotillomania and psychological problems must lead to this diagnosis. Bezoars can be fortuitously recognised by palpation of an epigastric abdominal mass while investigating anemia or esophageal reflux. This deviance is particularly dangerous. The first case of this series illustrates the Rapunzel syndrome with many perforations and necrosis of the small bowel. The 4 others are strict intragastric bezoars, quickly identified by echography. Treatment is exclusively surgical, digestion by papain or endoscopic extraction being impossible. Psychological assistance is mandatory.

Tricoses compulsivas

Por sua importância estética, os cabelos freqüentemente são alvo de interferências sociais, como é o caso de penteados e tinturas bizarras, e por vezes de auto-agressões. Os atos auto-agressivos mais freqüentes são: tricotilomania, tricotemnomania, tricofagia, tricoteiromania, pseudoalopecia da coçadura, tricocriptomania, tricorrexomania e plica neuropática. Neste artigo o autor discute detalhadamente as características clínicas e propedêuticas de cada doença, dando ênfase aos aspectos psiquiátricos dos pacientes.

Pancreatitis causing death in bulimia nervosa

OBJECTIVE

We report the case of a 19-year-old woman with bulimia nervosa who died of acute hemorrhagic pancreatitis. Our objective is to raise awareness that because the symptoms of both conditions are very similar, the pre-existence of an eating disorder should not distract physicians from the possibility that potentially lethal acute pancreatitis may coexist.

METHOD

The study includes autopsy results and a review of the literature.

RESULTS

Pancreatitis usually presents with abdominal pain, nausea, and vomiting.

DISCUSSION

In patients with eating disorders who may already have exhibited these symptoms pancreatitis may not be considered. Elevated serum amylase values may occur in subjects with bulimia nervosa without pancreatitis. If the serum amylase value is elevated, pancreatitis can be confirmed by measuring the levels of serum lipase, trypsinogen, pancreatic isoenzyme of amylase, or by abdominal computerized tomography (CT).

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.

Two-channel method for retrieval of gastric trichobezoar: report of a case

Large gastric trichobezoars usually are difficult to remove gastroscopically without gradual fragmentation. Surgical retrieval of trichobezoars may be recommended, which requires laparotomy and gastrotomy. The authors report a case in which an 11-year-old girl with a trichobezoar underwent successful removal using gastroscopy with laparoscopically assisted fragmentation.