Rapunzel syndrome in children: a retrospective review of ten cases combined with literature review in a tertiary referral center

PURPOSE

Rapunzel syndrome is an uncommon condition in children, and its clinical features remain unclear. This study presents the largest single-center series of pediatric cases to date, with the objective of documenting the clinical characteristics and treatment approaches for children with Rapunzel syndrome.

METHODS

A retrospective study was conducted in children with Rapunzel syndrome from 2019 to 2023. We recorded age, gender, symptoms, locations of bezoar, complications, and treatment options.

RESULTS

Ten patients with Rapunzel syndrome were included. The median age was 9.1 years, with all of whom were female. The most common clinical symptoms were upper abdominal mass (90%), abdominal pain (80%), and nausea and vomiting (50%). Complications occurred in six cases (60%), including small bowel obstruction (20%), severe gastric dilatation (10%), intestinal perforation (10%), choledochodilation (10%), acute pancreatitis with cholecystitis (10%). Preoperative ultrasonography suggested low-echoic foreign bodies continuing to the jejunum or ileocecal region in five cases (50%). Preoperative gastroscopy attempted in four cases (40%) to remove the foreign bodies, all of which failed. All patients underwent surgical treatment, with nine cases undergoing gastric incision foreign body removal, and one case undergoing gastric incision foreign body removal combined with intestinal perforation repair. All patients recovered well. No recurrence was observed during follow-up.

CONCLUSION

The accuracy of ultrasound diagnosis in identifying Rapunzel syndrome is high; however, it may lead to misdiagnosis if not complemented with the patient's medical history. Endoscopic presents a heightened treatment risk and a reduced success rate. The condition commonly presents with severe complications, thus making laparotomy a safe and effective option for intervention.

Trichotillomania, Trichophagia and Trichobezoar in a Male Paediatric Patient: A Case Report and Literature Review

INTRODUCTION AND IMPORTANCE

Trichotillomania and tricophagia, characterized by compulsive hair-pulling and subsequent ingestion which results in a compact mass of hair called trichobezoar. It represents an uncommon psychiatric disorder, especially in young children.

CASE PRESENTATION

This case report describes a distinctive and rare occurrence of trichotillomania, tricophagia and trichobezoar in a 11-year-old male child. Concerns raised by the parents regarding noticeable hair loss, who initially presented to medical outdoor patient with complaints of abdominal pain on and off from the last one year. He had a history of pica and weight-loss. He was then diagnosed with a gastric trichobezoar for which he was operated upon and a giant trichobezoar was retrieved from his stomach. Post-operatively patient remained admitted in ward and was discharged home on fifth post-operative day and sent for psychiatry evaluation.

CLINICAL DISCUSSION

Trichotillomania and tricophagia often have roots in psychosocial stressors, anxiety, and depression. Children may engage in hair-pulling as a coping mechanism, especially in response to familial or environmental stressors. The literature emphasizes the importance of understanding the psychosocial context to tailor interventions effectively.

CONCLUSION

Trichotillomania and tricophagia is very rare in paediatric population and if presents a multidisciplinary team comprising of a paediatrition, paediatric surgeon and paediatric psychiatrist should be involved and if diagnosed with a gastric trichobezoar should be removed surgically in order to prevent complications.

Gastrointestinal trichobezoars in the pediatric population: a retrospective study

BACKGROUND

Trichobezoar is an extremely rare condition characterized by a foreign body in the gastrointestinal tract (GIT) among children. The foreign body may exist in the digestive tract for several years, and it becomes evident if complications develop. The current study aimed to present 21 cases of GIT trichobezoars.

METHODS

Retrospective analysis of children who were diagnosed with trichobezoars between August 2012 and December 2022. Patient demographics, clinical presentation, diagnosis, and therapy were collected and analyzed.Twenty-one patients had GIT trichobezoars. Data were collected and analyzed retrospectively.

RESULTS

Twenty-one patients were identified. All patients were female. Their mean age at admission was 8.9 ± 1.9 years. Furthermore, 19 (90.5%) patients presented with abdominal pain, 16 (76.2%) with vomiting, and 13 (61.9%) with a palpable mass. Sixteen patients underwent gastroduodenoscopy. Among them, 15 had gastric trichobezoars. Moreover, 12 patients underwent computed tomography scan. Eight patients presented with gastric and small intestinal BZs, one presented with increased small intestinal contents with dilation, and one presented with abundant gastric contents. Then, 20 patients underwent surgery. Among them, five underwent laparoscopic-assisted minilaparotomy (LAML), and the rest underwent laparotomy. The results showed that 10 (50%) patients had gastric trichobezoars; 7 (35%), Rapunzel syndrome; and 3 (15%), small bowel trichobezoars. Two patients developed superficial wound infection postoperatively. One patient had a recurrent gastric trichobezoar.

CONCLUSION

Trichobezoar should be considered in young girls with a history of hair eating or those with hair in the vomit or feces. Timely diagnosis and aggressive treatment are the keys to reducing complications and improving prognosis. Laparoscopic-assisted minilaparotomy is a safe, feasible, and effective surgical method for treating trichobezoars.

A case of Rapunzel syndrome

Rapunzel syndrome is a rare disorder characterized by a trichobezoar in the gastroduodenal tract caused by trichophagia. Diagnosis was confirmed by upper endoscopy and treatment was surgical.

Trichobezoar Found Accidently while Diagnosing Resistance to Thyroid Hormone

Introduction

Bezoars are masses of indigestible foreign material in the gastrointestinal tract, usually in the stomach. These materials could be indigestible fruits, hair, milk products, or tablets. In children, the most common type of bezoar is trichobezoar (formed from hair).

Case Presentation

We describe a female patient who has been complaining about deterioration of mood, collapse without losing consciousness, scotomas, and cardiac arrhythmia for 2 years. Based on the results of thyroid hormone, resistance to thyroid hormone (RTH) was suspected. Physical examination during hospitalization revealed a palpable upper abdominal mass. Several diagnostic examinations were performed. The abdominal ultrasound showed acoustic shadowing caused by a pathological structure in the upper abdomen. Therefore, the contrast X-ray of the digestive tract revealed a deficit of contrast with an irregular shape in the stomach body and the pylorus region. Due to these results, a gastroscopy was performed, which revealed a large trichobezoar of the stomach. The trichobezoar was surgically removed without complications.

Conclusion

The case presented shows that these nonspecific symptoms and laboratory test suggesting RTH require multi-path diagnostics and the cooperation of many specialists, ultimately giving a surprising diagnosis. It is crucial to interpret diagnostic examinations with regard to the patient's physical condition. Diagnosis of trichobezoar requires a detailed search of causes to avoid another incident.

Revelation of Rapunzel syndrome: A rare case report of gastric trichobezoar-induced acute purulent peritonitis

INTRODUCTION AND IMPORTANCE

The Rapunzel syndrome embodies an uncommon variation of trichobezoar, predominantly observed among individuals with a history of psychiatric conditions, trichotillomania, and trichophagia. This combination of factors predisposes to the eventual formation of gastric bezoars. Trichobezoars, infrequent gastric masses composed of hair, can lead to complications if left untreated.

CASE REPORT

A 19-year-old female hairdresser with a history of trichophagia sought medical attention due to abdominal pain and episodes of vomiting. With an elevated body temperature and abdominal rigidity, imaging revealed the presence of a trichobezoar, accompanied by pneumoperitoneum and intraperitoneal effusion. Urgent surgical intervention confirmed the diagnosis of generalized purulent acute peritonitis, triggered by a gastric perforation caused by a 20 cm trichobezoar with an extension into the duodenum, which defines the Rapunzel syndrome. Gastrotomy was performed to remove the trichobezoar, followed by thorough peritoneal lavage.

CLINICAL DISCUSSION

Trichobezoar is a rare condition that involves the abnormal accumulation of solid substances, particularly hair, within the stomach. Known as "Rapunzel syndrome," it can extend into the duodenum or jejunum. Commonly associated with emotional disorders, trichobezoar can lead to symptoms like epigastric discomfort, vomiting, and weight loss. Diagnosis is through endoscopy, and treatments include fluid intake, endoscopic extraction, chemical dissolution, and surgical removal. Surgical intervention is often preferred, with laparoscopic approaches considered. Psychiatric management is often required for patients.

CONCLUSION

This case underscores the uncommon Rapunzel syndrome presentation, emphasizing timely surgical measures and multidisciplinary care for trichobezoars causing acute peritonitis.

Histopathologic diagnosis and patient characteristics in cats with small intestinal obstructions secondary to trichobezoars

OBJECTIVES

The aim of the present study was to describe the distribution of gastrointestinal histopathology findings associated with gastrointestinal obstructions secondary to trichobezoar formation in cats.

METHODS

A total of 100 surgical gastrointestinal biopsies were obtained from 44 cats with gastrointestinal obstructions secondary to a trichobezoar. Medical records, including signalment, type and duration of clinical signs, surgical reports and histopathologic analysis, were reviewed for each cat.

RESULTS

Biopsies taken near the site of the trichobezoar were more likely to show neutrophilic inflammation and mucosal erosion/ulceration compared with biopsies taken elsewhere in the small intestine. Lymphoplasmacytic and mixed lymphocytic and eosinophilic populations were the most common histopathologic findings from all biopsies followed by alimentary small cell lymphoma. Biopsy samples were more likely to represent a diagnosis of alimentary lymphoma in cats older than 10 years.

CONCLUSIONS AND RELEVANCE

Gastrointestinal biopsies taken at the time of surgery in cats with trichobezoar obstructions may represent an important diagnostic tool for further evaluation of potential feline chronic enteropathy. Biopsies taken at the site of the obstruction should be interpreted cautiously as the presence of a trichobezoar may induce an acute inflammatory reaction. The resultant histologic interpretation at this site may not represent the chronic state of the intestinal mucosa, supporting the utility of obtaining multiple biopsies orad and aborad to the obstruction.

Successful endovascular treatment of superior mesenteric artery-duodenal fistula secondary to Rapunzel syndrome

Rapunzel syndrome is a rare clinical entity in pediatric patients with a history of trichotillomania and trichophagia that has only been mentioned a few times in the literature. It is characterized by abnormal gastric bezoar formation that sometimes extends to the duodenum, jejunum, or colon. Here, we present a case of a 16-year-old previously healthy female patient who had prolonged hospitalization due to complications related to a significant gastric bezoar that led to massive bleeding due to a superior mesenteric artery (SMA)-duodenal fistula successfully treated with stent graft placement. Undiagnosed trichobezoar can lead to rare and unexpected complications, such as SMA-duodenal fistula, with life-threatening hemorrhagic shock. Prompt activation of massive transfusion protocol and endovascular control of the hemorrhage was vital to successfully treating our patient.

Mallory-Weiss syndrome from giant gastric trichobezoar: A case report

BACKGROUND

Mallory-Weiss syndrome (MWS), representing a linear mucosal laceration at the gastroesophageal junction, is a quite frequent cause of upper gastrointestinal bleeding, usually induced by habitual vomiting. The subsequent cardiac ulceration in this condition is likely due to the concomitance of increased intragastric pressure and inappropriate closure of the gastroesophageal sphincter, collectively inducing ischemic mucosal damage. Usually, MWS is associated with all vomiting conditions, but it has also been described as a complication of prolonged endoscopic procedures or ingested foreign bodies.

CASE SUMMARY

We described herein a case of upper gastrointestinal bleeding in a 16-year-old girl with MWS and chronic psychiatric distress, the latter of which deteriorated following her parents’ divorce. The patient, who was residing on a small island during the coronavirus disease 2019 pandemic lockdown period, presented with a 2-mo history of habitual vomiting, hematemesis, and a slight depressive mood. Ultimately, a huge intragastric obstructive trichobezoar was detected and discovered to be due to a hidden habit of continuously eating her own hair; this habit had persisted for the past 5 years until a drastic reduction in food intake and corresponding weight loss occurred. The relative isolation in her living status without school attendance had worsened her compulsory habit. The hair agglomeration had reached such enormous dimensions and its firmness was so hard that its potential for endoscopic treatment was judged to be impossible. The patient underwent surgical intervention instead, which culminated in complete removal of the mass.

CONCLUSION

According to our knowledge, this is the first-ever described case of MWS due to an excessively large trichobezoar.

Recurrent Rapunzel Syndrome in an Adolescent Female

Bezoars are concrete masses found within the gastrointestinal tract that can lead to obstructions. One of the most common forms of bezoars is trichobezoar, composed of swallowed hair. Many bezoars are confined to the stomach; however, a small occurrence of trichobezoars extends past the pylorus and into the duodenum, or small bowel, termed Rapunzel syndrome. In the literature, there have been few cases of recurrent Rapunzel syndrome. Our case is a 13-year-old female with recurrent Rapunzel syndrome requiring three operative interventions.

Trichobezoar-A rare cause of hyperemesis in a pregnant woman

Bezoars consist of ingested foreign material or organic matter which forms a mass in the gastrointestinal tract, usually in the stomach. Trichobezoars formed by swallowed hair may present with vomiting, malnutrition, weight loss or abdominal pain with signs of gastrointestinal obstruction. There are limited case reports of Trichobezoar during pregnancy. We present a case of young pregnant women who was admitted on few occasions with vomiting in early pregnancy and was treated as hyperemesis gravidarum. Failure of response to conventional management prompted further investigation, revealing trichobezoar. Our case highlights the diagnostic challenge posed by trichobezoars in young pregnant women.

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 trichobezoar and Rapunzel syndrome: case report of a very rare condition

Background

Rapunzel syndrome is a rare trichobezoar variant extending from the gastric cavity into the small bowel.

Case description

We report the case of a 22-year-old woman who presented with epigastric pain, nausea, and loss of appetite within the preceding five weeks. She had a palpable mass in the epigastric area with mild localized tenderness. Her abdominal computed tomography scan showed a distended stomach and duodenum, with a heterogeneous solid material, suspicious for a bezoar. Upper gastrointestinal endoscopy revealed a large, densely packed trichobezoar occupying the gastric cavity and extending through the pylorus. Endoscopic removal of the bezoar was unsuccessful. The patient underwent a 6cm-long gastrotomy, and the 150cm-long bezoar, extending from the stomach to the jejunum, was uneventfully removed. The patient was referred postoperatively to a dietitian and psychiatrist for management of her trichotillomania and trichophagia.

Conclusion

Trichobezoars are commonly found in young females with a history of trichotillomania and trichophagia and are associated with psychiatric disorders. HIPPOKRATIA 2023, 27 (1):25-27.

An incidental finding of Rapunzel syndrome in a case of perforated appendix in a young girl

A bezoar is a mass of indigestible foreign material found in the gastrointestinal tract, usually in the stomach. Trichobezoars are the second most common bezoars which are usually found in young psychiatric patients. A 15-year-old female patient presented with signs of intestinal obstruction and acute abdomen. The preoperative investigations revealed a perforated appendix, and an exploratory laparotomy was performed. Intraoperative findings showed presence of a mass of hair in the stomach along with a long tail extending into the small intestine. Postoperatively, the patient's condition worsened and she died because of complications of perforation peritonitis on day 3. Early diagnosis of Rapunzel syndrome can help in making early interventions. The prognosis of incidental detection of this condition depends on the accompanying cause.

Sex Differences in Age at Onset and Presentation of Trichotillomania and Trichobezoar: A 120-Year Systematic Review of Cases

Trichotillomania (hair-pulling disorder) has high female preponderance. It has been suggested that onset in early childhood represents a distinct developmental subtype that is characterized by higher prevalence of males compared to later onset cases. However, the empirical literature is scarce. We conducted a systematic review of case reports to examine the distribution of age at onset/presentation in males and females with trichotillomania or trichobezoar (a mass of hair in the gastrointestinal tract resulting from ingesting hair). We identified 1065 individuals with trichotillomania and 1248 with trichobezoar. In both samples, males, compared to females, had earlier age at presentation and greater proportion of cases in early childhood. These sex differences remained after potential confounding variables were accounted for. The results showed similar sex differences for age at onset, which was reported in 734 and 337 of the trichotillomania and trichobezoar cases, respectively. The findings may reflect neurodevelopmental underpinnings in early childhood trichotillomania.

Uncommon cause of respiratory failure due to a bezoar in the hypopharynx: a case report

Background

Trichotillomania and trichophagia cause trichobezoars, which are masses made of hair. The main presentation of this condition is abdominal pain. However, other complications include gastric outlet obstruction, nausea, vomiting, weight loss, malnutrition, hematemesis, diarrhea, and constipation.

Case presentation

A 57-year-old woman with trichotillomania was admitted to the Emergency Department with the chief complaints of dyspnea on exertion, shortness of breath, dysphagia, generalized weakness, and hoarseness. Spiral chest computed tomography (CT) scan did not reveal any parenchymal lesions Pulmonary CT angiography did not reveal pulmonary embolism. The patient was admitted to the Surgery Department for hand fasciotomy due to contrast leakage, and during laryngoscopy, a trichobezoar was detected that was removed with Magill forceps.

Conclusions

Rare cases of trichobezoars can be observed in humans with gastrointestinal and respiratory symptoms. Precise and timely diagnosis are key for the prevention of more invasive diagnostic procedures.

Esophageal obstruction due to trichobezoar in a she-camel (Camelus dromedarius)

Background

Occurrences of esophageal foreign bodies are common in camels. Esophageal obstruction in camels due to bezoars is rare.

Case Description

This report describes esophageal obstruction in camel due to trichobezoar. A 2-year-old she-camel presented with a history of inability to swallow and there was food and water regurgitation for one day before. Radiography and endoscopic examination revealed an oval-shaped foreign body embedded in the esophageal lumen in the level distal third of the neck. The foreign body was successfully removed using cervical esophagotomy under general anesthesia. Successful esophagostomy revealed trichobezoar weighing 45 g and measuring 85 mm × 75 mm × 42 mm. The trichobezoar removed from the esophagus was the cause of esophageal obstruction.

Conclusion

Esophageal obstruction in camel could be due to trichobezoar. Radiography and endoscopy are valuable diagnostic methods to determine the position and nature of an obstructive object.

Rapunzel Syndrome. A rare cause of intestinal obstruction

BACKGROUND

Rapunzel syndrome is the formation of a trichobezoar that extends beyond the small intestine. Since its discovery few cases have been reported in the literature with variable clinical characteristics, causing important complications such as intestinal obstruction. Laparotomy is currently considered the treatment of choice.

CASE REPORT

We present the clinical case of a patient who presented with recurrent peritonitis associated with a peritoneal dialysis catheter, anorexia, nausea, vomiting, without channeling or presenting evacuations, epigastric tumor, anxiety, trichotillomania and trichophagia. Rapunzel syndrome is diagnosed and admission to the operating room is decided.

Large trichobezoar associated with misdiagnosis, a rare case report with a brief literature review

Introduction

Trichobezoar is a rare disorder that almost exclusively affects young females. Up to 90% between 13 and 20 years of age. The current study aims to report and discuss a rare case of Misdiagnosis of Trichobezoar.

Case presentation

A 14-year-old girl student patient admitted to the Baxshin hospital, with a large trichobezoar filling the entire stomach with a long tail of hair extending within the pylorus into the proximal jejunum at a length of 70 cm; associated with abdominal pain, constipation, and vomiting. Laboratory data showed mild iron deficiency anemia, with a normal liver, and renal function test, patients' electrolytes showed a normal profile. Confirmation of the presence of the mass was done through abdominal Computed Tomography (CT) with contrast. The physician initially diagnosed as alopecia and suspected the abdominal pain was related to the postprandial emesis because the patient didn't provide a history of trichotillomania and used treatment for alopecia for a long time.

Discussion

The presence of a mass in the abdomen of a child is considered one of the most severe findings. Physical examination of the patient plus a full history taken, and the age of the patients provide a clear clue to the origin of the mass. Further investigation, including laboratory data and imaging findings, provides better understanding and a firm diagnosis. Trichobezoar should be considered by the physicians in this case.

Conclusion

In the early diagnosis of the trichobezoar, the physicians should investigate for any medical history of clinical trichophagia, trichotillomania, or a psychological problem.

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The initial step of trichobezoar diagnosis is a direct question about consuming hair.

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Trichobezoar formation is caused by a delay in diagnosing trichotillomania and trichophagia.

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Physicians should investigate for any medical history of trichophagia, trichotillomania, or a psychological problem.

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The clinical feature of trichobezoar usually associated with alopecia of the scalp and other regions of the body

Trichobezoar

Teaching point: A trichobezoar is a relatively rare entity that presents on imaging as a heterogeneous and multilayered mass molded by the stomach lumen.

A huge abdominal mass revealing a depressive syndrome

Trichobezoar is a rare condition that occurs mostly in young women with psychiatric disorders such as trichotillomania and trichophagia. We report the case of a giant gastric trichobezoar in a 21-year-old woman who presented with chronic abdominal pain, vomiting and weight loss. Abdominal examination revealed a large epigastric mass. Endoscopic and imaging findings were highly suggestive of a gastric trichobezoar. Surgical extraction of the huge hair mass was successfully performed through an open gastrotomy. Postoperatively, history of a neglected chronic depression with suicidal ideation was diagnosed. Consequently, the patient was referred to the psychiatric department for mental healthcare, to prevent trichobezoar recurrences.

Trichobezoar from bristles brush and Carpet yarn requiring emergency laparotomy. Case report

Introduction and importance

When hair accumulates inside the stomach, it causes what is called a Trichobezoar, which leads to a stomach blockage, this condition is rare and more common in women and in patients with psychiatric disorders.

Case presentation

The authors report an unusual case of a 16-year-old girl who has trichobezoar not only by ingestion of hair, it is also by bristle clothes brush and Carpet yarn. she presented with acute abdominal pain and gastrointestinal symptoms-like watery diarrhea, vomiting, hypercoria and weight loss attributed to Anorexia. With an upper gastroscopy, the condition was diagnosed as a huge Trichobezoar that occupied the stomach. The patient was managed by surgical removal of the intra gastric mass.

Clinical discussion

Affected patients infrequently remain asymptomatic for several years. Symptoms begin while the bezoar increases in size to the point of obstruction, these symptoms are nonspecific like vomiting, nausea, anorexia, asymptomatic abdominal mass and digestive bleeding.

Conclusion

Trichobezoar considers as a differential diagnosis for any patient with psychological disorders, like trichotillomania and trichophagia and has gastrointestinal symptoms.

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Trichobezoar considers as a differential diagnosis for any patient with psychological disorders, like trichotillomania and trichophagia and has gastrointestinal symptoms.

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Trichobezoar is caused by chronic ingestion of hair; Small trichobezoars may be extracted by endoscopic fragmentation, huge trichobezoar, on the other hand need surgical removal.

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Early diagnosis and an appropriate therapy can reduce morbidity and mortality.

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Psychological counselling plays a pivotal role in order to prevent bezoar recurrence

Gastrointestinal trichobezoar: An experience with 17 cases

BACKGROUND

Trichobezoar is an exceedingly rare entity in children and mimics other chronic ailments such as abdominal tuberculosis or malignancy. Delayed diagnosis and management result in various complications. The study was conducted to describe our experience with 17 consecutive cases of gastrointestinal tract (GIT) trichobezoars.

MATERIALS AND METHODS

We reviewed medical records of 17 consecutive cases of GIT trichobezoar managed in our department between January 2005 and December 2018.

RESULTS

There were 3 males and 14 females. The median age of presentation was 7 years. Fifteen patients (88%) presented with abdominal pain and vomiting, while 8 (47%) had abdominal distension. Seven (41%) patients developed complications secondary to the GIT trichobezoar (intussusception and gangrene in 1, small bowel obstruction in 4, gastric perforation and massive bleeding per rectum in 1, acute transient pancreatitis and hypertension in 1). At operation, 9 (54%) patients had Rapunzel syndrome, 6 (35%) had gastric trichobezoar, and 2 (12%) had small bowel trichobezoars. One patient presented with massive bleeding per rectum and gastric perforation, succumbed postoperatively. One patient developed a recurrent trichobezoar.

CONCLUSION

GIT trichobezoar is rare in children and simulates chronic gastrointestinal ailments. Trichobezoars may reside in the alimentary tract, remain unnoticed for years, and become overt with the onset of complications. The majority of trichobezoars had a tail in our series. Life threatening complications can occur with delayed presentations.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

Level IV.

Rapunzel Syndrome in Congenital Mental Retardation Patient Requiring Emergency Laparotomy. Case report

Introduction

When hair accumulates inside the stomach, it causes what is called a Trichobezoar, which leads to a stomach blockage. When the accumulated hair extends into the small intestine, it causes a rare disturbance called Rapunzel syndrome (RS).

Discussion

Affected patients infrequently remain asymptomatic for several years. Symptoms begin while the bezoar increases in size to the point of obstruction, these symptoms are nonspecific like vomiting, nausea, anorexia, asymptomatic abdominal mass and digestive bleeding.

Presentation of case

The authors report an unusual case of a 25 years old young woman who presented with acute abdominal pain and gastrointestinal symptoms. With an upper gastroscopy, the condition was first diagnosed as a Trichobezoar that occupied the stomach. A decision to perform a surgical procedure was taken, only to discover, during the procedure, that the mass was extended to the duodenum and jejunum, thus diagnosing the condition as Rapunzel syndrome. The patient was managed by surgical removal of the huge mass.

Conclusion

Trichobezoar considers as a differential diagnosis for any patient with mental retardation and has gastrointestinal symptoms.

Laparoscopic removal of massive pediatric gastric trichobezoars: A brief report

BACKGROUND

Trichobezoars are foreign bodies in the gastrointestinal tract composed of ingested hair. These can develop into large, hard, obstructing objects that are often impossible to remove endoscopically. The size often leads surgeons to remove these via laparotomy or laparoscopic-assisted procedure (midline laparotomy for specimen removal), with few removed completely laparoscopically.

BRIEF REPORT

We present a case of a 5-year-old female with pica who had symptoms of foul-smelling diarrhea and weight loss and was found to have a massive gastric trichobezoar. The bezoar was removed laparoscopically with pfannensteil incision facilitating specimen extraction. Further, technical aspects of the procedure are discussed.

CONCLUSION

We conclude that there are benefits to using a laparoscopic approach to remove a massive gastric trichobezoar. This includes the use of a Pfannensteil incision rather than a midline laparotomy for specimen removal.

Giant gastroduodenal trichobezoar: A case report

BACKGROUND

We report a case of giant gastroduodenal trichobezoar, an extremely rare upper gastrointestinal bezoar due to trichotillomania and trichophagia.

CASE SUMMARY

The patient was a 10-year-old girl who presented with an abdominal mass that was discovered at palpation and noninvasive imaging examinations. Computed tomography (CT) showed a well-circumscribed heterogeneous mass extending from the stomach into the duodenum. The patient underwent a laparotomy to pull out the trichobezoar. Although these imaging findings are nonspecific, trichobezoar should be included in the differential diagnosis of gastric mass, especially with the history of an irresistible urge to pull out and swallow their hair.

CONCLUSION

Laparotomy is useful and practical for the management of giant gastroduodenal trichobezoar.

Trichobezoar in a young girl caused by ingestion of bristles brush for more than a decade: A case report

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Ingestion of hair and bristle brush led to unique type of trichobezoars.

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Trichobezoars led to gastric outlet obstruction.

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The diagnosis is made by abdominal X-ray, computed tomography scan and endoscopic examination.

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Surgical intervention is performed for the majority of patients.

Introduction

Trichobezoar is a rare cause of bowel obstruction. In general, Trichobezoars are composed of hair and usually found incidentally in patients undergoing upper gastrointestinal endoscopy or imaging. Patients diagnosed with Trichobezoar may have psychiatric disorders.

Discussion

Trichobezoars cause nonspecific symptoms like asymptomatic abdominal mass, vomiting, nausea, and anorexia. Diagnosis of Trichobezoar is made by endoscopic examination and radiological methods. Therapeutic options for trichobeazoar are chemical dissolution, endoscopic removal or surgery.

Case presentation

Here we present a case of an 18-year-old girl who has a unique type of Trichobezoars caused by ingestion of hair and bristle clothes brush for 14 years. She presented to the surgical clinic complaining of vomiting, anorexia and epigastric mass. Abdominal computed tomography scanner showed nonattached intragastric mass which was consistent with trichobezoar. The patient was managed by surgical removal of the intragastric mass.

Conclusion

Trichobezoar is caused by chronic ingestion of hair; it is commonly seen in young females who may have psychological disorders, such as trichophagia and trichotillomania. Common symptoms are abdominal pain, nausea, vomiting, and weight loss. Surgical intervention is performed for the majority of the patients.

Intraluminal bezoar caused obstruction and pancreatitis: A case report

Acute pancreatitis from bezoar-induced obstruction is rare. We present an uncommon case report of a man with manifestations of Rapunzel syndrome with no known history of mental disorders. Surgical removal of the bezoar through gastrostomy and enterotomy in the absence of a psychiatric undertone will undoubtedly prevent a relapse.

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.

Best management modality of trichobezoar: A case report

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Laparotomy is the best treatment method for trichobezoare.

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Psychiatric management should be done for any patient with trichotillomania to avoid trichobezoar.

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Endoscopic treatment can only be successful for small trichobezoar.

Introduction

Trichobezoar is a rare condition, usually diagnosed in children and young female especially with psychiatric illness. Diagnosis of trichbezoar is usually dependent on the disease history, examination, diagnostic modality including CT scan. Generally this condition can be treated by endoscopy, laparoscopy or laparotomy. Here, we have presented a rare case of trichobezoar which has failed to be treated endoscopically but was eventually treated successfully by laparotomy.

Case report

A 17 years old girl was presented with the initial complaint of epigastric pain for about 9 months duration with symptoms including vomiting and weight loss. Clinical examination showed tenderness and hard mass over epigastric area and it was extending towards the right hypochondrial area. CT scan results also showed that the stomach was filled with large intra-luminal abnormal mass like contents with mottled air pattern extended to fill the pylorus and first part of the duodenum. These findings were the proofs for possible trichobezoar. Endoscopic surgery failed significantly and hence laparotomy was performed, as a result, trichbezoar was removed successfully.

Discussion

Trichobezoar can be treated by using endoscopy for removal of hair, laparoscopy or Laparotomy. Laparotomy had 100% successful rate while 5% for endoscopy and 75% for laparoscopy.

Conclusion

Laparotomy is the best treatment method for trichobezoare. Psychiatric management should be done for any patient with trichotillomania to avoid trichobezoar.

Surgical outcome of jejunum-jejunum intussusception secondary to Rapunzel syndrome: a case report

Background

Adult intestinal intussusception is a rare condition caused by the mechanical disruption of bowel motility. A bezoar is defined as indigestible material inside the gastrointestinal tract that develops into a trapped mass; the most frequent bezoar is a trichobezoar. When a trichobezoar extends into the small intestine it is defined as Rapunzel’s syndrome. Literature describing complications related to this pathology remains scarce.

Case presentation

A 16-year-old Mexican girl presented to our emergency room with acute abdomen and a presumptive diagnosis of intestinal obstruction. Computed tomography was suggestive of intussusception. Surgery confirmed a jejunal-jejunal intussusception with a mass within the gastric cavity extending into her small intestine, corresponding to a trichobezoar. A manual intussusception reduction and a gastrotomy with extraction of the trichobezoar were performed.

Conclusions

We present a case of a jejunum intussusception as a complication of Rapunzel syndrome. Our patient had a favorable outcome after surgical intervention with a manual intussusception reduction, with retrograde displacement of the trichobezoar into the gastric lumen, and a complete extraction through a gastrostomy. Follow-up included psychiatric evaluation.

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.

[Gastroduodenal trichobezoar: about a case]

Le trichobézoard gastroduodénal est une affection rare, dont le diagnostic est facile en présence d'un contexte évocateur. Nous rapportons le cas d'une jeune patiente âgée de 21 ans suivie pour une schizophrénie, admise pour douleur abdominale aiguë, vomissements et masse épigastrique, le scanner abdominal a permis de faire suspecter un bézoard en objectivant des lésions hétérogènes occupant tout l'estomac, ne prenant pas le contraste et semblant indépendante de la paroi gastrique. Un traitement chirurgical a été réalisé avec exérèse du trichobézoard par gastrotomie, sans complications et un transfert en service de psychiatrie.

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.

Recurrent Rapunzel syndrome - A rare tale of a hairy tail

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Rapunzel syndrome is a rare condition in which gastric trichobezoar extends beyond the pylorus and into small intestine.

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Diagnosis is by ultrasound, upper gastrointestinal series, CT scan and upper gastrointestinal endoscopy.

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The trichobezoar mass can be removed via laparotomy(gastrotomy and enterotomy) or endoscopic approach.

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long-term follow-up with surgical and psychiatric consultation is recommended to prevent recurrences.

Introduction

Rapunzel syndrome is a rare condition predominantly found in trichophagic females that occurs when gastric trichobezoar extends beyond the pylorus and into duodenum, jejunum, ileum or even to colon. There are only five cases reported in literature. This case report has been reported in line with the SCARE criteria.

Presentation of case

A 19 year old female, with a history of trichotillomania with trichophagia, who presented with epigastric pain and vomiting for 12 months. She underwent laparotomy ten years back to extract a trichobezoar, which was diagnosed to be Rapunzel syndrome and lack of follow-up resulted in recurrence. Further examination and imaging showed a large trichobezoar extending into small intestine. She underwent gastrotomy and entrerotomy and extraction of hairball.

Discussion

In a trichophagic female with abdominal pain, nausea and vomiting, and abdominal mass, diagnosis is done by ultrasound, CT scan and upper gastrointestinal endoscopy. Small trichobezoars can be removed endoscopically. Large (>20 cms)acutely symptomatic trichobezoars, especially when accompanied by Rapunzel syndrome, must be removed surgically by gastrotomy and enterotomy is required if impacted extension is present. Long-term surgical and psychiatric follow-up with psychotherapy and cognitive behavioural therapy along with selective serotonin reuptake inhibitors are critical to prevent recurrences.

Conclusion

Although Rapunzel syndrome is an extremely rare disease, it should be considered when diagnosing young women, especially those with a history of trichophagia or trichotillomania. After the surgical removal of trichobezoars by laparotomy, long-term follow-up combined with psychiatric consultation is recommended to prevent recurrences.

A novel finding of Rapunzel syndrome

Rapunzel syndrome is a rare form of gastric trichobezoar (hair ball) involving extension of a tail of the hair into the small bowel. A 13-year-old girl was admitted with a 4-day history of epigastric pain and nausea which worsened after meals. Abdominal ultrasound showed duodenal wall thickening and lymphadenopathy. Esophagogastroduodenoscopy identified a gastric trichobezoar with a tail extending into the duodenum. In addition, multiple longitudinal duodenal and jejunal ulcers were noted. The ulcers appeared to be a result of direct pressure by the tail itself against the intestinal mucosa. The trichobezoar was successfully retrieved endoscopically under general anesthesia. Her symptoms resolved completely after retrieval. Psychiatric follow-up was carried out to help reduce the risk of recurrence. Here, we describe a novel complication of Rapunzel syndrome, i.e., multiple longitudinal ulcers of the small intestine. This novel finding suggests that the mucosal damage caused by the trichobezoar of Rapunzel syndrome can occur in an earlier stage than previously thought. In addition, we also strongly recommend using general anesthesia with intubation when removing a gastric trichobezoar to ensure protection of the airway.

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.

Rapunzel Syndrome

A bezoar refers to a mass of undigestible foreign material found in the gastrointestinal tract, mainly stomach. The second most common bezoar is the trichobezoar, which usually occurs in the young psychiatric female patients with history of trichotillomania and trichophagia. This is a case report of a 12 -year-old female patient came with complaints of diffuse abdominal pain, vomiting, and constipation. Ultrasound, Barium X-ray and Computed Tomography scan were done, which suggested trichobezoar. Thus, trichobezoar should be considered as differential diagnosis of abdominal pain in young female patients with associated psychiatric complaints. A review is presented here, as a high index of suspicion for better diagnostic facilities which can help in timely diagnosis and intervention, to prevent further complications like intestinal obstruction, perforation and mortality in such children.

Gastric Perforation due to Giant Trichobezoar in a 13-Year-Old Child

Trichotillomania and trichotillophagia can cause the formation of enormous intragastric hairballs. We report the case of a 13-year-old girl who was brought to the emergency service for evaluation of an acute abdomen. Abdominal CT scanner showed a giant gastric trichobezoar which had to be removed by susombilical laparotomy and transverse gastrotomy. This case illustrates the fairly uncommon perforation risk of these gastric bezoars.

Trichobezoar presenting as a gastric outlet obstruction: A case report

INTRODUCTION

Rapunzel syndrome is a rare intestinal condition that starts with the ingestion of a trichobezoar. The condition is predominately found in females and can be associated with trichotillomania, or the compulsive urge to pull one's own hair out. There are less than 40 cases described in the literature with the prevention of recurrence aimed at psychological treatment.

PRESENTATION OF CASE

The patient is a 7 year-old girl with a history of trichotillomania with trichophagia as a young child who presented with abdominal pain, nausea, and vomiting, consistent with a gastric outlet obstruction. She had an exploratory laparotomy with gastrostomy performed revealing a 18cm by 18cm trichobezoar with extension into the small bowel.

DISCUSSION

Bezoars, an already rare entity, can occasionally lead to gastric and small bowel obstructions. Small collections of ingested hair build up in the intestinal tract causing significant symptoms. These obstructions can sometimes be treated through minimally invasive techniques but, in our case described, it is unlikely to have been treated any other way due to the substantial size of the trichobezoar.

CONCLUSION

Early consideration of Rapunzel syndrome is important in young females presenting with a gastric outlet obstruction.

A hairy situation: trichobezoar presenting with intussusception, and intestinal and biliary perforation in a child

Trichobezoars are an uncommon cause of acute abdominal pain. We present a case of a 12-year-old girl with a history of a trichobezoar who presented to the emergency department with acute abdominal pain. Abdominal sonography was performed which suggested portal venous gas and showed complex peritoneal fluid. Subsequent computed tomography demonstrated both gastric and small bowel bezoars, with a jejunojejunal intussusception, and confirmed portal venous gas and complex ascites. At the time of surgery, there was evidence of intestinal and biliary perforation. Our case illustrates a constellation of complications in association with a long-standing trichobezoar.

A rare clinic entity: Huge trichobezoar

INTRODUCTION

Trichobezoar is a rare clinical entity in which a ball of hair amasses within the alimentary tract. It can either be found as isolated mass in the stomach or may extend into the intestine. Trichobezoars mostly occur in young females with psychiatric disorders such as trichophagia and trichotillomania.

CASE REPORT

Authors present a giant trichobezoar in an 18year old female presented with complaints of upper abdominal mass, epigastric area pain, anorexia and weight loss. The patient underwent trans-abdominal ultrasonography (USG), Computed tomography (CT), upper gastrointestinal endoscopy and subsequently laparotomy. USG was inconclusive due to non-specific findings. It revealed a thick echogenic layer with posterior dirty shadowing extending from the left sub-diaphragmatic area to the right sub hepatic region obscuring the adjacent structures. Abdominal CT images revealed a huge, well defined, multi-layered, heterogeneous, solid appearing, non-enhancing mass lesion in the gastric lumen extending from the gastric fundus to the pyloric canal. An endoscopic attempt was performed for removal of this intraluminal mass, but due to its large size, and hard nature, the endoscopic removal was unsuccessful. Finally the large trichobezoar was removed with open laparotomy.

CONCLUSION

Trichobezoars should be suspected in young females with long standing upper abdominal masses; as the possibility of malignancy is not very common in this age group. While USG is inconclusive, trichobezoar can be accurately diagnosed with CT. In patient with huge trichobezoar, laparotomy can be performed firstly because of big size and location of mass, and psychiatric recommendation should be made to prevent relapse of this entity.

Rapunzel syndrome due to ingested hair extensions: Surgical and psychiatric considerations

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Consuming hair extensions can lead to intestinal obstruction.

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Massive gastric trichobezoar extending into the duodenum is termed Rapunzel syndrome.

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Rapunzel syndrome often requires surgical intervention.

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Patients with Rapunzel syndrome require close psychiatric follow-up.

Introduction

Rapunzel syndrome is a unique clinical manifestation of trichotillomania and trichophagia. The resulting gastric trichobezoar can be massive and necessitate surgical extraction.

Presentation of case

We present a case involving a 15 year-old female with a known history of trichotillomania. The patient possessed symptoms of nausea and early satiety, and admitted that she had recently consumed a large number of hair extensions. Computed tomography imaging revealed a massive gastric bezoar not amenable to endoscopic extraction. The patient underwent surgical laparotomy, and a large gastric trichobezoar was removed through an anterior gastrotomy. The trichobezoar extended past the pylorus into the duodenum, thus confirming a diagnosis of Rapunzel syndrome.

Discussion

Trichobezoars formed from the consumption of hair extensions is a rare cause of Rapunzel syndrome. Surgical extraction is often necessitated due to the sheer size of the gastric bezoar that results from consuming hair extensions. If not previously established, psychiatric consultation should be pursued in the immediate post-operative course as these patients may require pharmacologic management along with behavioral therapy to avoid further episodes of trichotillomania.

Conclusion

This case presents a unique and modern manifestation of Rapunzel syndrome. Surgical treatment most often is required when a patient presents with a massive gastric trichobezoar. Regular post-operative psychiatric follow-up is necessary to prevent recurrent episodes.

Uncommon Presentation of Gastric Trichobezoar: A Case Report

Every material that gastrointestinal system cannot digest will make a bezoar. Trichobezoar is the result of hair ingestion whether self-hair or from others and is not a common disorder in humans. It is a hairball, which mostly has been seen in females at teenage, or adolescence. It usually locates in stomach but in rare conditions, it will pass through the intestine, and make the Rapunzel syndrome. Herein we present a 13-year-old girl suffering from gastric trichobezoar presenting with failure to thrive.

Review of the diagnosis and management of gastrointestinal bezoars

The formation of a bezoar is a relatively infrequent disorder that affects the gastrointestinal system. Bezoars are mainly classified into four types depending on the material constituting the indigestible mass of the bezoar: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars. Gastric bezoars often cause ulcerative lesions in the stomach and subsequent bleeding, whereas small intestinal bezoars present with small bowel obstruction and ileus. A number of articles have emphasized the usefulness of Coca-Cola^® administration for the dissolution of phytobezoars. However, persimmon phytobezoars may be resistant to such dissolution treatment because of their harder consistency compared to other types of phytobezoars. Better understanding of the etiology and epidemiology of each type of bezoar will facilitate prompt diagnosis and management. Here we provide an overview of the prevalence, classification, predisposing factors, and manifestations of bezoars. Diagnosis and management strategies are also discussed, reviewing mainly our own case series. Recent progress in basic research regarding persimmon phytobezoars is also briefly reviewed.

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.

A trichobezoar in a child with undiagnosed celiac disease: A case report

Celiac disease is a chronic, immune-mediated enteropathy caused by a permanent sensitivity to ingested gluten cereals that develops in genetically susceptible individuals. The classic presentation of celiac disease includes symptoms of malabsorption but has long been associated with cognitive, emotional, and behavioral disorders. We describe an 8-year-old patient with non-scarring alopecia and diagnosed with trichotillomania. Furthermore, she presented with a 3-year history of poor appetite and two or three annual episodes of mushy, fatty stools. Laboratory investigations showed a normal hemoglobin concentration and a low ferritin level. Serologic studies showed an elevated tissue immunoglobulin G anti-tissue transglutaminase level. A duodenal biopsy showed subtotal villous atrophy and crypt hyperplasia, and a large gastric trichobezoar was found in the stomach. Immediately after beginning a gluten-free diet, complete relief of trichotillomania and trichophagia was achieved. In this report, we describe a behavioral disorder as a primary phenomenon of celiac disease, irrespective of nutritional status.