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.

[The placement of colonic stents in emergency surgery]

INTRODUCTION

The treatment for malignant colonic obstruction usually consists in a diverting colostomy. The usefulness colorectal stent to resolve the occlusion is a new interesting application to prevent unnecessary operation.

METHODS

From September 1999 to June 2005 73 patent underwent the positioning of colorectal stent for colorectal cancer or extrinsic compression under double fluoroscopic and endoscopic control. In 35 patient the stent was inserted as palliative measure, and 38 underwent stent as bridge to surgery.

RESULTS

The placement of the stent was achieved in all patient, with 94% (69/73) of clinical success. Perforation occurred in two patient, one related to the guide wire and the other to balloon dilatation of the stent. Reobstruction occurred in 3 patient and migration in 9. The mortality after stent placement was 4.1% (3/73). We perform a colostomy or an ileostomy in 4 patient bridge to surgery and in 4 palliative, for a total of 8 stoma (10.95%).

CONCLUSION

The usefulness of colorectal stent can be consider an alternative to colostomy especially in unresectable patients.

[Second look yes, second look no, in the surgical therapy of intestinal infarct]

The thorny second-look problem is examined on the basis of personal experience of 65 cases of intestinal infarction over a period of 10 years. The medical literature is particularly lacking in indications on this point and only from careful assessment of reported experience and personal experience itself has it been possible to find indications and limitations. Data are reported which do not pretend to be absolute but do provide a useful aid for those faced with doubtful anatomopathological pictures during operation for acute intestinal ischaemia.