Trichophagia and trichobezoar: case report

Bezoars: Culprits of gastrointestinal obstruction that may lead to surgical intervention and potentially surgical complications

Key Clinical Message

Bezoars can cause gastrointestinal obstruction and may require surgery. Surgery carries the risk of complications. Medical professionals should perform detailed history in diet and behaviors for patients presenting with abdominal pain to identify risk factors for bezoars, then educate these patients and their families about risks and complications of bezoars.

Abstract

Bezoars are solid masses of undigested material that can cause obstruction of the gastrointestinal tract. There are different types of bezoars; phytobezoar, trichobezoar, pharmacobezoar, lactobezoar, and bezoars containing tissue paper or polystyrene foam. This case report is of a 13-year-old Hispanic male who suffered a postsurgical complication after removal of bezoar. He had a past surgical history of appendectomy and presented to the hospital with a 1-day history of right lower quadrant abdominal pain associated with fever and diarrhea. X-radiation images and computed tomography scans aided in the diagnosis of pelvic abscess as a complication of postsurgical enterotomy and closure of the enterotomy to remove bezoar from the small bowel. The initial bezoar removal and the postsurgical complication of pelvic abscess resulted in the patient staying for 19 days in the hospital. At discharge, the patient and his guardian were advised to follow up with the patient's primary care physician and surgical team. The patient made an uneventful recovery. He did not experience any long-term complications and fully recovered. This report demonstrates that although bezoars are rare, they can cause significant obstruction of the gastrointestinal tract leading to the need for management, such as surgery, which carries its own risks. It is important to note that the postsurgical complication of pelvic abscess can occur due to surgery itself and not because of bezoar specifically. Abdominal surgery in general poses the risk of pelvic abscess. The consideration is to expectantly decrease the occurrence of bezoars so that consequently there will not be a need for surgery in removal of bezoars due to obstruction. The effects of bezoars can be prevented through educating the community and addressing underlying psychiatric disorders.

Uncommon, overlooked and underreported causes of upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGB) is a potentially fatal consequence of digestive disorders. There is a wide range of rare causes for UGB that can lead to misdiagnosis and occasionally catastrophic outcomes. The lifestyles of those who are afflicted are mostly responsible for the underlying conditions that result in the hemorrhagic cases. The development of a novel approach targeted at raising public awareness of the issue and educating the public about it could significantly contribute to the elimination of gastrointestinal bleeding with no associated risks and to a nearly zero mortality rate. There are reports of UGB related to Sarcina ventriculi, gastric amyloidosis, jejunal lipoma, gastric schwannoma, hemobilia, esophageal varices, esophageal necrosis, aortoenteric fistula, homosuccus pancreaticus, and gastric trichbezoar in the literature. The common feature of these rare causes of UGB is that the diagnosis is difficult to establish before surgery. Fortunately, UGB with a clear lesion in the stomach itself is a clear sign for surgical intervention, and the diagnosis can only be verified by pathological examination with the help of immunohistochemical detection of a particular antigen for a specific condition. The clinical traits, diagnostic techniques, and the therapeutic, or surgical options of unusual causes of UGB reported in the literature are compiled in this review.

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.

Trichobezoar without a clear manifestation of trichotillomania

Trichophagia is a compulsive condition characterized by eating hair, mostly seen in adolescent females. Persistence of ingestion of hair over many years results in the formation of trichobezoar. Surgical intervention is often needed in the management of large trichobezoars. We present a case of a 23 year old female with trichophagia which led to the formation of gastric trichobezoar. The patient reported with complaints of pain in abdomen for past 1–2 years, and loss of appetite and vomiting post meals for 6 months. On detailed examination, a diagnosis of trichobezoar was formed which was removed by laparotomy with gastrotomy under general anaesthesia. Psychiatric evaluation revealed a history of fluctuating mood symptoms during her childhood and depressive symptomatology presently without any associated urge of plucking hair and subsequent gratification. Hence, the management of the disease requires proper liaison between the surgeon, psychiatrist, and caregivers of the patient; and regular psychiatric follow-up and treatment of the underlying psychopathology to prevent the recurrent formation of bezoar.

Trichobezoar with and without Rapunzel syndrome in paediatric population: A case series from a tertiary care centre of Northern India

INTRODUCTION

Trichobezoars are concretions formed by accumulation of hair in stomach. Usually, trichobezoar is confined to the stomach, but rarely it may extend from the stomach to the small intestine and even colon. This is an unusual form called Rapunzel syndrome. Our experience with this rare entity of Rapunzel syndrome and interesting entity of trichobezoar is being presented with review of literature.

PRESENTATION OF CASES

We, at our institute, encountered four cases of trichobezoar in last five years, out of which two were found to be of Rapunzel syndrome. All of these cases were managed successfully by open surgical intervention in view of the very large size of the mass in all the cases.

DISCUSSION

The clinical presentation is highly variable ranging from asymptomatic cases diagnosed incidently to serious gastrointestinal symptoms and complications. Cases of trichobezoar have been reported in literature very infrequently but Rapunzel syndrome is extremely rare and less than 50 cases have been reported in medical literature till date.

CONCLUSION

Trichobezoar leading to Rapunzel syndrome is an extremely rare entity. The clinical presentation is usually vague and non-specific. Treatment is mainly surgical because of delayed presentation in majority of the cases. Psychiatric illness is the usual association.

[Nephrotic syndrome in a female patient with Rapunzel syndrome]

The Rapunzel syndrome is a rare complication of gastric trichobezoar, which may be long insidious. Systemic hair eating gradually leads to bezoar growth, gastritis, gastric mucosal ulcerations, and evacuatory disorders. The Rapunzel syndrome may cause acute and chronic bowel obstruction, peritonitis, pancreatitis, appendicitis, anemia, hypoalbuminemia, and allergic manifestations. Neither proteinuria nor nephrotic syndrome is depicted in any of the 38 Rapunzel syndrome cases described in the literature. The authors present the first case of gastric trichobezoar extending to the small bowel (its total length was 118 cm), which gave rise to chronic recurrent partial bowel obstruction, causing intoxication nephrotic syndrome in a 20-year-old women with trichotillomania. The nephrotic syndrome became a reason for her admission to a nephrology department and had specific features: it was unaccompanied by hypercholesterolemia, it rapidly regressed and completely disappeared after surgical removal of the trichobezoar weighing 1980 g.

Trichophagia along with trichobezoar in the absence of trichotillomania

Trichobezoars are rarely described in the absence of trichotillomania. In this report we present a case of trichobezoar associated with trichophagia in the absence of trichotillomania. A 16-year-old girl presented to surgery outpatient with complaints of pain in abdomen and vomiting for the last 6 months. Physical examination revealed a 14 × 16 cm firm, tender, mass with smooth surface, irregular margins, which was mobile with respiration. Ultrasound abdomen revealed a bizarre lesion in the right upper and middle abdomen suggestive of gastric bezoars. Upper gastrointestinal endoscopy did not reveal any abnormality in the esophagus and showed a large mobile mass in the stomach. In view of trichobezoar, psychiatry consultation was sought. Exploration of history revealed that the patient was eating hairs and clay since early childhood. As per patient she would eat hairs thrown by others. She would like the taste of hair and had strong persistent desire to eat hair and would go out searching for the same. At times she would also eat clay. However, she denied of pulling her own hairs. Physical examination of scalp and other body parts did not show any evidence of alopecia or pulling of hair/short hair. She was managed surgically and was counseled about the consequences of eating hairs and clays and was encouraged not to eat hair. To conclude our case suggests that patients can have trichobezoar and trichophagia even in the absence of trichotillomania.

Gastric trichobezoar associated with perforated peptic ulcer and Candida glabrata infection

Bezoars are accumulations of human or plant fiber located in the gastrointestinal tract of both humans and animals. Patients remain asymptomatic for several years, and the symptoms develop as these accumulations increase in size to the point of obstruction or perforation. We report the case of a 21-year-old patient at 10 d postpartum, who presented with acute abdomen associated with sepsis. Given the urgency of the clinical picture, at no point was the presence of a giant bezoar at gastric level suspected, specifically a trichobezoar. The emergency abdominal and pelvic ultrasound revealed only unspecific signs of perforated hollow viscus. Diagnosis was therefore made intraoperatively. A complete gastric trichobezoar was found with gastric perforation and secondary peritonitis. The peritoneal fluid culture revealed Candida glabrata.

Unusual trichobezoar of the stomach and the intestine: a case report

INTRODUCTION

Trichobezoars are an infrequent form of bezoar found in the stomach or intestine, created from ingested hair. This condition has been well described in the surgical literature, but less reported in psychiatry.

CASE PRESENTATION

We describe the case of an 18-year-old Middle Eastern Caucasian woman with trichotillomania who presented to our emergency department with a history of central abdominal pain associated with vomiting and constipation for five days. An examination showed a trichobezoar requiring emergent surgical intervention, and indicating the need for psychiatric treatment. The trichobezoar was treated successfully by laparotomy.

CONCLUSION

The medical and psychiatric sequelae of trichotillomania should not be underestimated, and early diagnosis and treatment is of utmost importance to save the patient's life and prevent recurrence. Although laparotomy is still considered an excellent option, pharmacotherapy and behavioral assessment play a useful role in patient management. Our case highlights the fundamental concept of a holistic approach rather than only treating the symptoms, by considering factors such as genetic influences to understand the disease.

Rapunzel Syndrome in a Postpartum Patient after Caesarian Delivery

A trichobezoar is an immobile, indigestible collection of hair or hair-like fibers that accumulates within the GI tract. Rapunzel syndrome is a rare variant in which a trichobezoar extends into the small intestine, potentially causing obstruction. We describe the first case, to our knowledge, of Rapunzel syndrome occurring in a postpartum patient after delivery by Caesarian section.

Recurrent trichobezoar due to trichophagia: a case report

OBJECTIVE

Trichobezoar, a hair ball in the gastrointestinal tract, is usually the result of the urge to pull out one's own hair (trichotillomania) and swallow it (trichophagia). It is almost exclusively seen in young females and may cause serious medical complications. This case report will describe an adult female patient with recurrent trichobezoars.

METHOD

Data for this case report was collected from peer-reviewed literature and treatment encounters by the consultation-liaison psychiatry unit; subsequent to obtaining informed consent.

RESULTS

The personality characteristics, familial structure and domestic stress found in this case mirror the literature. We initiated behavioral interventions including habit reversal training and patient education in combination with pharmacologic therapy with clomipramine.

CONCLUSION

Left untreated, trichophagia can cause a life-threatening emergency, requiring surgery. Recurrence of tichobezoars can be anticipated when the underlying emotional disorder is not addressed using multimodal management including psychiatric evaluation and treatment combined with surgical procedures.