A rare clinic entity: Huge trichobezoar

IntroductionTrichobezoar 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 reportAuthors present a giant trichobezoar in an 18 year 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.ConclusionTrichobezoars 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.     

Gastric perforation due to trichobezoar in an adult (Rapunzel syndrome)

Rapunzel syndrome, or trichobezoar, is an uncommon entity and secondary gastric perforation is exceptional. We found no adult cases reported in the literature. Our patient is a teenager with clinical symptoms of epigastric mass and acute abdomen. Radiological study showed pneumoperitoneum and intragastric mass. Personal history revealed depressive syndrome and anxiety. Urgent laparotomy confirmed the diagnosis of gastric perforation due to a trichobezoar completely moulding the gastric chamber. The diagnosis was suspected on the basis of radiologic images but laparotomy was required to confirm it.     

Das Rapunzel-Syndrom

The Rapunzel syndrome is a rare manifestation of a gastric trichobezoar with a "tail" extending throughout the small intestine and sometimes even to the colon. We report on the surgical removal of such a bezoar in a 4-year-old patient by gastrotomy--the third published case in the German literature. The syndrome is mainly seen in young girls with trichophagia psychodynamically associated with early childhood deprivation and a high comorbidity of serious pediatric psychiatric disorders. The symptoms are nonspecific and may mimic those of other pathologic gastrointestinal conditions. Clinical characteristics are a movable mass in the epigastrium and alopecia. The therapy of choice is surgery of the trichobezoar together with the whole intestinal "tail," as in most cases endoscopic removal fails due to the large extension. Early diagnosis and treatment of the Rapunzel syndrome is of eminent importance in order to avoid later fatal complications such as gastric perforation and intestinal necroses. Intensive psychiatric follow-up is mandatory for preventing relapses.     

Rapunzel syndrome: A rare presentation with multiple small intestinal intussusceptions

Bezoars are usually confined to the stomach which is seen in individuals with psychiatric illness like trichotillomania, trichophagia and gastric dysmotility. Long standing bezoars may extend into the small intestine leading to a condition known as Rapunzel syndrome. Diagnosis can be established by endoscopy, ultrasonography and computed tomography scan. Treatment includes improvement of general condition and removal of bezoar by laparoscopic approach or laparotomy. Psychiatric consultation is necessary to treat and prevent relapse. We report a case of Rapunzel syndrome in a 16-year-old girl with trichotillomania. She presented with history of epigastric mass for three months and recent onset of pain abdomen, vomiting and early satiety. Skiagram of abdomen was showing distended stomach and endoscopy revealed trichobezoar. At laparotomy, stomach was distended with trichobezoar and there were multiple small intestinal intussusceptions. Gastrotomy and manual reduction of intussusceptions with the removal of trichobezoar with its tail was done. Patient recovered completely after the procedure.     

Trichobezoar: A rare cause of bowel obstruction

A bezoar is an intraluminal mass formed by the accumulation of undigested material in the gastrointestinal tract. A trichobezoar is a bezoar made up of hair and is a rare cause of bowel obstruction of the proximal gastrointes-tinal tract. They are seen mostly in young women with trichotillomania and trichotillophagia and symptoms include epigastric pain, nausea, loss of appetite and bowel or gastric outlet obstruction. We herein describe a case of a trichobezoar that presented as a gastric outlet obstruction and was subsequently successfully removed via a laparotomy.     

Gastric trichobezoar: one case report

The gastric trichobezoar is a rare disease in which diagnosis is easy in case of evocative context. Its treatment is not standardized. The authors report the case of a 9 year old girl, known to have trichophagy, presenting with a large epigastric mass. Upper endoscopy made the diagnosis of a trichobezoar. Surgical extraction was performed through gastrotomy, without complications. Psychiatric follow-up was recommended.     

Laparoscopic treatment of a large trichobezoar in the stomach with gastric perforation and abdominal wall abscess

Trichobezoar represents a mass of swallowed hair inside the stomach. Here we report a 17-year-old girl who presented in our department with symptoms of gastric ulcer. Ultrasound examination followed by upper endoscopy revealed a large trichobezoar in the stomach with simultaneous gastric perforation. Laparoscopy also revealed a penetration into the anterior abdominal wall accompanied by abscess at this level. We performed a laparoscopic gastrotomy with trichobezoar extraction and laparoscopic treatment of perforation and abdominal wall abscess. The postoperative evolution was normal and the patient was discharged on the fifth postoperative day. We show that laparoscopic approach may be safely used in the treatment of the large gastric complicated trichobezoar. Several laparoscopic approaches were described for the treatment of tricobezoar and its complications but as far as we know this is the first report of laparoscopic treatment of large tricobezoar and associate gastric perforation.     

Rapunzel Syndrome Complicated with Gastric Perforation Diagnosed on Operation Table

Rapunzel syndrome is a variety of trichobezoar with the main body in the stomach and the tail extending into the small or large bowel. Twenty-seven cases of Rapunzel syndrome have been reported in the literature so far. This particular case of Rapunzel syndrome was on table diagnosis in a case of gastric perforation. The bezoar was removed and the patient was given psychiatric consultation.     

Unusual presentation of Rapunzel syndrome

Background

The Rapunzel syndrome is an unusual form of trichobezoar found in patients with a history of psychiatric disorders, trichotillomania (habit of hair pulling) and trichophagia (morbid habit of chewing their hair) who subsequently develop gastric bezoars. The principal symptoms are vomiting and epigastric pain.

Case presentation

A 15-year-old female presented with a two-month history of continuous dull aching epigastric pain, vomiting, loss of appetite and weight loss. Further examination and imaging showed a large trichobezoar. Nevertheless, the patient refused any intervention. A few days later, she presented to the emergency department with features of peritonitis. After adequate resuscitation, she was taken for exploratory laparotomy. Her postoperative course was uneventful.

Conclusion

Delayed treatment of Rapunzel syndrome can lead to a complication such as gastric perforation which albeit extremely rare, could prove catastrophic.     

Unusual Cause of Palpable Mass in Upper Abdomen—Giant Gastric Trichobezoar: Report of a Case

A trichobezoar is a ball of swallowed hair that accumulates in the stomach and fails to pass through the intestines. Usually a trichobezoar presents in early satiety and malnutrition. Obstructive symptoms and manifestations of gastric outlet obstruction may occur. While small gastric trichobezoars may be removed via gastroscopy, large trichobezoars require surgical removal by gastrotomy through abdominal incision. We present a case of a successful mini-laparotomy removal of a giant gastric trichobezoar in a 15-year-old girl with a history of trichophagia for a long time and marginal psychological disturbances.     

Rapunzel syndrome and gastric perforation

Rapunzel syndrome complicated with gastric perforation is a very rare presentation of trichobezoar. Trichobezoar is an uncommon condition affecting predominantly females. It has non-specific clinical presentation, a wide range of complications, and, if not treated appropriately, carries significant mortality. Traditional treatment of trichobezoar is surgical, though, attempts have been made to excise endoscopically, dissolve chemically or fragment using extracorporeal shock waves. We report a case of a very large trichobezoar occupying most of the stomach and duodenum complicated with gastric perforation, and summarise the literature regarding trichobezoar aetiology, diagnostic difficulties, and management.     

Unusual cause of palpable mass in upper abdomen--giant gastric trichobezoar: report of a case

A trichobezoar is a ball of swallowed hair that accumulates in the stomach and fails to pass through the intestines. Usually a trichobezoar presents in early satiety and malnutrition. Obstructive symptoms and manifestations of gastric outlet obstruction may occur. While small gastric trichobezoars may be removed via gastroscopy, large trichobezoars require surgical removal by gastrotomy through abdominal incision. We present a case of a successful mini-laparotomy removal of a giant gastric trichobezoar in a 15-year-old girl with a history of trichophagia for a long time and marginal psychological disturbances.     

Laparoscopic removal of a gastric trichobezoar in a pregnant woman

We describe the laparoscopic removal of a gastric trichobezoar performed on an 18-year-old woman in her second trimester of pregnancy. The laparoscopic removal of a gastric trichobezoar has not previously been described in an adult. Laparoscopy during pregnancy is never without the fear of harm including spontaneous abortion of the developing fetus, however, increasing cumulative worldwide experience suggests that there is no significant difference in fetal morbidity with laparoscopy when compared with laparotomy. A review of laparoscopy in pregnancy with regard to this case is presented.     

Laparoscopic removal of a huge gastric trichobezoar in a patient with trichotillomania

Gastric bezoars are rare, and are commonly observed in female children with mental or emotional disorders. Large bezoars may not be suitable for endoscopic extraction and are conventionally removed at laparotomy. We present a 19-year-old girl who had trichotillomania with a symptomatic abdominal mass that represented a 17-cm gastric trichobezoar. This was removed laparoscopically through a gastrotomy in a water-impervious bag and was extracted piecemeal through a 4-cm extension of one of the port wounds. The bezoar weighed 720 g. She was discharged home on the third postoperative day and remains symptom-free at 12-month follow-up. Laparoscopic removal of large gastric trichobezoars is feasible and appears safe.     

Rapunzel Syndrome: A Case Report and Review

We report a 14-year-old girl who presented with epigastric pain, vomiting, and an upper abdominal mass. A diagnosis of trichobezoar was made on ultrasound and she went on to have a laparotomy, where a large trichobezoar was extracted with a tail that extended into the small intestine.     

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.     

Laparoscopic removal of massive pediatric gastric trichobezoars: A brief report

BackgroundTrichobezoars 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 reportWe 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.ConclusionWe 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 Trichobezoar and Gastric Perforation in a Normal Healthy Woman

We present a case report of a mentally healthy woman who had gastric trichobezoar leading to perforation. A pertinent review of literature is included.     

Beware of the flaming hairball--a brief review and warning

Operating room fires are receiving increasing attention in the medical literature and in the general public. The best way to reduce these iatrogenic, sometimes devastating, events is communication and education. The authors present the case of a 14-year-old adolescent girl who had an apparent explosive event during a laparotomy for removal of a large gastric trichobezoar. This event was presumably associated with gas production under increased pressures in the gastrointestinal tract caused by an obstructive and decomposing trichobezoar. This is the first reported association between trichobezoars and potential intraoperative fire and/or injury. It is the recommendation of the authors to avoid the use of electrocautery when initially entering a portion of the gastrointestinal tract thought to contain a bezoar to avoid the potential for surgical fire or concussive tissue damage.     

Trichobezoar presenting as a gastric outlet obstruction: A case report

IntroductionRapunzel 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 caseThe 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 18 cm by 18 cm trichobezoar with extension into the small bowel.DiscussionBezoars, 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.ConclusionEarly consideration of Rapunzel syndrome is important in young females presenting with a gastric outlet obstruction.