Trichobezoar

Point-of-Care Ultrasound of a Pediatric Gastric Trichobezoar: A Case Report

ABSTRACT

This case report describes a previously healthy pediatric patient with acute onset of abdominal pain and distention who was found to have an epigastric mass on physical examination. Point-of-care ultrasound (POCUS) demonstrated a large gastric mass with ultrasonographic features consistent with a trichobezoar. After POCUS was performed, trichophagia was confirmed on history, and the patient went to the operating room for removal of a large trichobezoar. We conclude POCUS may be helpful for evaluation of epigastric masses and diagnosis of gastric trichobezoars. We review the ultrasound technique, sonographic findings, and literature regarding ultrasound diagnosis of trichobezoars.

Two cases of Rapunzel syndrome in adult males

Trichobezoar are foreign bodies formed from undigested hairs that accumulate in the gastrointestinal tract and cause obstruction. Trichobezoar are usually found in the stomach but when the tail of the bezoar extends into the small intestine it is referred to as Rapunzel syndrome. Patients are usually females and have a history of psychiatric illness. However, in this study, we present two cases of Rapunzel syndrome in adult male patients that were managed with surgery. Trichobezoar should be considered in all patients with a history of psychiatric illness presenting with abdominal symptoms regardless of gender.

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.

Gastric Perforation With Peritonitis Secondary to a Trichobezoar: A Literature Review and Report of a Rare Presentation

Trichobezoar, a rare disorder commonly seen in psychiatric patients having a habit of plucking and eating their own hair, is a ball of hair admixed with gastro-intestinal secretions that leads to the blocking of the passage of food particles. Presentation of the disease is variable, ranging from asymptomatic to severe complications including obstruction and perforation. We report a case of a 27-year-old female patient who presented with an acute abdomen and on laparotomy, gastric perforation secondary to large gastric trichobezoar was found. The patient was treated with en bloc removal of the trichobezoar.

Huge trichobezoar presenting as abdominal mass and weight loss: Case report

INTRODUCTION

Trichobezoar is a condition in which hair is accumulated in the stomach forming a ball like mass. Human hair is resistant to digestion and peristalsis therefore over time it accumulates in the gastric folds. Trichophagia and trichotillomania is a psychiatric disorder in which the affected person has the tendency to pull her or his own hair and ingest it. The condition is almost exclusively seen in females.

CASE PRESENTATION

A 48-year-old lady presented for the last 6 months with epigastric pain, early satiety and weight loss. There are episodic attacks of vomiting. Abdominal examination showed a large, 30 cm × 15 cm, firm, oval shaped mass occupying the left hypochondrial region and extending below the umbilicus. The mass was mobile from side to side but not from up and down it has smooth surface. The mass was non pulsatile. The CT scan of the abdomen was taken and it showed a large oval mass with interspersed gas. Endoscopy showed a huge ball of hair occupying the whole gastric cavity and extending to the upper part of the duodenum. During laparotomy a huge hair mass extracted from the stomach.

CONCLUSION

Trichobezoar is an extremely rare condition that may be encountered during the surgical practice, high index of suspicion is needed to diagnose the condition and endoscopy is still the gold standard method for investigation and diagnosis. The main treatment modality if the open surgery. All patients need psychiatric consultation and long term follow up.

Surgical Removal of Numerous Foreign Body Gastric Bezoar: A Case Report

A 53-year-old mentally retarded male was brought to our emergency room after vomiting a plastic glove. Computed tomography revealed marked gastric distention containing large amount of residual food debris. Endoscopic retrieval was unsuccessful. Surgical removal of the foreign bodies was done. The patient did well and was discharged from the hospital.

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.

Rapunzel syndrome: an infrequent cause of severe iron deficiency anemia and abdominal pain presenting to the pediatric emergency department

Background

Iron deficiency anemia (IDA) and abdominal pain are commonly seen in a pediatric emergency department (8 and 18% incidence respectively in our center). They are manifestations of a wide variety of diseases ranging from benign to immediately life-threatening. Trichobezoar is an under-diagnosed entity that has to be considered in children and adolescents, expecially female, suffering from trichotillomania (compulsion to pull hair) and trichophagy (compulsion to swallow hair). When undiagnosed, gastric bezoars may cause gastric ulceration, perforation, haemorrhage and obstruction.

Case presentation

To underline the importance of including this pathology in the differential diagnosis of IDA and abdominal pain, we present the case of a 14 year-old girl with a huge trichobezoar which completely filled the stomach and extended into the small bowel. Since trichobezoar has an extension to the small bowel, it is classified as Rapunzel syndrome. As the bezoar couldn’t be removed by endoscopy, the girl underwent surgical intervention. The patient passed through a gradual re-feeding, with iron and vitamins supplementation, and through a psychiatric counselling.

Conclusion

The Rapunzel syndrome is a rare entity that may be complicated by life-threatening events. A prompt diagnosis and an appropriate therapy can reduce comorbidities. Gradual re-feeding with supplementation of micronutrients allows adequate catch-up weight with normalization of haematochemical nutritional parameters. Since many of these patients suffer from psychiatric pathology such as PICA with emotional problems and mental retardation, psychological/psychiatric counselling plays an important role in order to prevent bezoar recurrence.

A Rare Case of an Early Postoperative Obstructive Ileus in a Young Female Patient due to a Residual Trichobezoar Mass

Trichobezoar is a rare cause of small bowel obstruction, whereby a mass forms most commonly in the stomach and duodenum of young females, from ingestion of hair, a condition known as trichophagia. We present a case of recurrent small bowel obstruction due to a residual hair mass that was removed surgically in a young female patient who had a laparotomy and gastrotomy for removal of a large gastric trichobezoar just two weeks prior to the current admission. This case illustrates the importance of a thorough inspection of the whole bowel to ensure that no residual bezoars remain after surgery.

Rapunzel syndrome presenting as jejuno-jejunal intussusception

The term Rapunzel syndrome is used to describe a trichobezoar of the stomach with a long tail of hair extending into the duodenum and small intestine. It is a rare clinical entity, and it is even rarer in these cases that jejuno-jejunal intussusception and resulting intestinal obstruction is a presenting feature. We report one such case, a young female who presented in the emergency department with abdominal pain and bilious vomiting of short duration. Contrast-enhanced CT of the abdomen enabled a diagnosis of a trichobezoar in the stomach extending into the small gut, along with jejuno-jejunal intussusception. On exploration, gastrotomy was performed to remove the gastric trichobezoar, and jejuno-jejunal intussusception was found on three segments in the proximal jejunum, which was resolved upon complete removal of the tail of the bezoar. This case report is unusual, since intussusception is a rare occurrence in Rapunzel syndrome, and this is the first time that it has been diagnosed preoperatively.

Double and synchronous trichobezoars causing small-bowel obstruction and detected by multidetector computed tomography: report of two cases

A trichobezoar is a rare mass formed by the ingestion and accumulation of hair within the gastrointestinal tract, especially the stomach. Cases of an isolated gastric trichobezoar with extension into the duodenum or the jejunum have been reported; however, synchronous gastric and intestinal trichobezoars causing a small-bowel obstruction is very unusual. We report our experience of two such cases to demonstrate the efficiency of preoperative multidetector computed tomography in locating the double bezoars and assisting us in surgical decision making. Open surgery is inevitable for symptomatic bezoars, because the masses are too hard and large to break up with endoscopic devices.

Trichobezoar: a diagnosis which is hard to swallow and harder to digest

An 11-year-old girl with normal development and good academic progress at school presented with an abdominal mass. She lived with her aunt as her mother suffered from severe bipolar disorder and was unable to raise her. There were also multiple bereavements in the family. She had a history of alopecia and admitted to have eaten her hair to relieve stress. Examination was normal apart from a solid mass in the left hypogastrium. CT abdomen revealed a huge intra-abdominal mass covering most of the lumen. Open laparotomy was performed to remove the mass which was confirmed to be a trichobezoar. She made a good postoperative recovery and was discharged after 7 days. She has been referred to psychology services. Bereavement alone without psychiatric, physical disability or autism can be associated with trichobezoar. More studies are needed to study the association of trichotillomania, trichophagia and trichobezoar.

A Hairy Tail not a Fairy Tale - Rapunzel Syndrome

Rapunzel syndrome is an unusual and rare type of trichobezoar. Bezoars can be classified according to the primary constituent, as trichobezoar (hair), phytobezoar (plant material) or miscellaneous (pharmacobezoar, lactobezoar, fungal agglomeration and foreign bodies). When a long tail of hair strands extends from the main mass in the stomach along the small intestine and beyond it is known as Rapunzel syndrome. Here we are reporting a case of Rapunzel syndrome with a very long tail who was managed successfully. And reviewing the literature on the pathophysiology and management of these patients. These patients commonly present with obstructive symptoms and needs a high index of suspicion especially, in young female patients who have alopecia circumscripta and underlying psychiatric disorders. Early diagnosis and treatment is required to prevent complications due to this condition. Currently surgical management of this condition is the treatment of choice.

Laparoscopic treatment of gastric bezoar

Detailed in this report is the laparoscopic removal of a gastric bezoar through an anterior wall gastrotomy.

A seventeen-year-old female presented with a symptomatic abdominal mass that was diagnosed by barium meal and computed tomography to be a gastric bezoar. She underwent laparoscopic removal of the bezoar, through an anterior wall gastrostomy in an endobag, which was extracted piecemeal through a 4-cm upper midline incision.

The technique is described with a review of a few previous laparoscopic-assisted cases.

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.

Child with small bowel obstruction and perforation secondary to ileal bezoar

Bezoars are a rare cause of intestinal obstruction, but morbidity and mortality of late diagnosis and complication are high. Generally, bezoars remain in the region of the stomach; however, infrequently, they will pass to the small bowel. The clinical diagnosis of bezoar is challenging, and initial radiographs are frequently nondiagnostic. Early recognition of this entity on plain film or by computed tomography is important to prevent late complications. In addition, bezoar formation can indicate underlying psychiatric disorder that requires evaluation and therapy. We present a child with classic radiographic trichobezoar that had passed to the distal ileum and resulted in subsequent perforation.

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.

Simultaneous gastric and small intestinal trichobezoars--a hairy problem

A trichobezoar represents a mass of accumulated hair within the gastrointestinal tract. Isolated gastric trichobezoars, those with extension into the duodenum, and small intestinal trichobezoars have all been described. However, the presence of discrete gastric and intestinal trichobezoars has been rarely presented in the literature. This case report describes synchronous trichobezoars in the stomach and jejunum in a 9-year-old girl presenting with abdominal pain, anorexia, and vomiting. This case emphasizes the role of radiographic imaging in the diagnosis of trichobezoars and the importance of a complete clinical evaluation of the small bowel at the time of removal of an obstructing gastric bezoar.