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1.  Huge simultaneous trichobezoars causing gastric and small-bowel obstruction 
Bezoars are concretions of foreign materials that impair gastrointestinal motility or cause intestinal obstruction in the stomach, small intestine or bowel of humans or animals. There are many types of them such as phyto, lacto and trichobezoars. Although bezoars are not rare, multiple giant bezoars which totally fill the stomach lumen and have extension to the small intestine (Rapunzel syndrome) are very rare. This is a case report of a young girl who had a history of trichophagia and presented with partial gastric and intestinal obstructive signs. The patient was healthy, and her physical exam was almost normal and the only positive thing in her past medical history was trichophagia from several years ago. She had a big trapped bobble in her stomach and several air-fluid levels in abdominal radiograph and was investigated with endoscopy which confirmed the diagnosis of a huge gastric trichobezoar.
PMCID: PMC3252776  PMID: 22247733
Bezoars; Gastric Outlet Obstruction
2.  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 gastrointestinal 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.
doi:10.4240/wjgs.v3.i4.54
PMCID: PMC3083501  PMID: 21528095
Obstruction; Bezoar; Trichobezoar; Trichotillomania
3.  Gastric Trichobezoar Causing Intermittent Small Bowel Obstruction: Report of a Case and Review of the Literature 
Case Reports in Medicine  2011;2011:217570.
We report the unusual case of a 45-year-old woman who presented with multiple episodes of small bowel obstruction. Initial exploratory lap-roscopy did not reveal an etiology of the obstruction. Subsequent upper endoscopy identified a non-obstructing gastric trichobezoar which could not be removed endoscopically but was not thought to be responsible for the small bowel obstruction given its location. One week postoperatively, the patient experienced recurrence of small bowel obstruction. Repeat endoscopy disclosed that the trichobezoar was no longer located in the stomach and upon repeat laparotomy was extracted from the mid-jejunum. In the following 8 months, the patient had no further episodes of small bowel obstruction. Consequently, gastric bezoars should be included in the differential diagnosis of recurrent small bowel obstruction.
doi:10.1155/2011/217570
PMCID: PMC3114431  PMID: 21687591
4.  Laparoscopic Intragastric Removal of Giant Trichobezoar 
This report describes a laparoscopic approach for the removal of a large gastric bezoar.
Background and Objectives:
Gastric bezoars are a rare clinical entity, most commonly observed in patients with mental or emotional illness. Large bezoars can be difficult to remove laparoscopically without extending a port incision.
Methods:
We report the case of a large symptomatic trichobezoar with Rapunzel syndrome that occurred in a 17-year-old girl who had trichotillomania.
Results:
The bezoar was removed laparoscopically, in piecemeal fashion, through a gastrotomy port. This procedure did not require an extension of any incision, nor did it require the contents of the stomach to directly touch the incision, thereby reducing the risk of infection. The patient was discharged home, on the fourth postoperative day, free of any complications.
Conclusion:
This case illustrates the safety of the laparoscopic approach in the removal of large gastric bezoars. In considering use of this approach, the potentially long operative time must be weighed against the benefits of both minimal risk of infection and minimal incisions.
doi:10.4293/108680810X12785289144520
PMCID: PMC3043579  PMID: 20932380
Trichobezoar; Gastric outlet obstruction; Rapunzel syndrome; Trichotillomania
5.  Unusual cause of gastric outlet obstruction: giant gastric trichobezoar: a case report 
Cases Journal  2008;1:399.
Background
Trichobezoars are caused by hair ingestion. The usual presentation of a trichobezoar is with early satiety and malnutrition. Obstructive symptoms and manifestations of gastric outlet obstruction may occur. The diagnosis may be suspected in young females with malnutrition, who have a history of trichophagia.
Case presentation
We report a case of 12-year-old female admitted to the emergency room for abdominal pain. On physical examination, she was cachectic and an epigastric mass was palpated. An exploratory laparotomy was conducted. A giant trichobezoar was palpated in the stomach and was removed through an anterior gastrostomy.
Conclusion
There were no complications postoperatively and the patient was referred to a psychiatrist.
doi:10.1186/1757-1626-1-399
PMCID: PMC2634769  PMID: 19087240
6.  A Giant Trichobezoar Causing Rapunzel Syndrome in a 12-year-old Female 
Bezoar is a tightly packed collection of undigested material that is unable to exit the stomach. Most bezoars are of indigestible organic matter such as hair-trichobezoars; or vegetable and fruit–phytobezoars; or a combination of both. Trichobezoars commonly occur in patients with psychiatric disturbances who chew and swallow their own hair. In very rare cases, the Rapunzel syndrome hair extends through the pylorus into the small bowel causing symptom and sign of partial or complete gastric outlet obstruction. A case report of trichobezoar in the stomach causing Rapunzel syndrome in a 12-year-old female is reported.
doi:10.4103/0253-7176.85401
PMCID: PMC3195161  PMID: 22021959
Rapunzel; syndrome; female; giant; trichobezoar
7.  Laparoscopic Removal of a Large Gastric Trichobezoar in a 4-Year-Old Girl 
Laparoscopic removal of a large gastric trichobezoar is technically feasible through small incisions without requiring port-site extension or limited midline laparotomy.
Background:
Standard treatment of large gastric bezoars not amenable to medical or endoscopic management is surgical removal. The optimal operative approach, laparotomy versus laparoscopy, is a contested subject. Though laparoscopic removal has been described, it remains a relatively new technique for surgical management with outcome literature limited to case reports. In addition, currently described laparoscopic techniques often involve limited midline laparotomy incisions or >3 cm extensions of port sites.
Methods:
The following describes the case of a 4-year-old girl with a large gastric trichobezoar.
Results:
The gastric trichobezoar was successfully removed through a 12-mm left lower quadrant trocar incision cosmetically hidden within a skin crease.
Conclusion:
This case, along with accumulating literature, supports the use of laparoscopy to treat large gastric bezoars.
doi:10.4293/108680809X12589999538110
PMCID: PMC3030801  PMID: 20202404
Bezoar; Trichobezoar; Laparoscopy
8.  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.
doi:10.1186/1752-1947-8-79
PMCID: PMC3946194  PMID: 24580892
Bezoar; Endoscopy; Iraq; Laparoscopy; Mass; Rapunzel syndrome; Trichobezoar; Trichotillomania
9.  Trichobezoar presenting with the 'comma sign' in Rapunzel Syndrome: a case report and literature review 
Cases Journal  2008;1:286.
Introduction
Rapunzel Syndrome is an uncommon presentation of trichobezoar, involving strands of swallowed hair extending as a tail through the small intestine, beyond the stomach. This was first described in 1968 and until 2003 only thirteen cases have been reported.
Case Presentation
A 55-year old man of East Indian descent presented to the surgical team via the emergency department in Trinidad, West Indies, with an acute abdomen and small bowel obstruction. He had a recent psychiatric history and patchy alopecia as well as a family history of schizophrenia. A supine abdominal radiograph revealed a small bowel obstruction as well as an unusual air shadow in the left hypochondrium in the region of the duodeno-jejunal flexure associated with the stomach bubble, which resembled a 'comma'. At laparotomy, the stomach and third part of the duodenum were distended and contained a large mass of dark, foul-smelling hair that occupied the stomach, crossed the pylorus and extended into the small bowel. A retroperitoneal perforation of the third part of duodenum was found and repaired. The large trichobezoar was removed via a gastro-enterotomy and the patient made a slow, but complete recovery.
Conclusion
We wish to report another case of Rapunzel Syndrome and describe an unusual radiologic sign associated with a retroperitoneal perforation of the third part of duodenum – the comma sign. To the best of our knowledge this is the first reported case of a spontaneous retroperitoneal perforation of the third part of duodenum associated with Rapunzel Syndrome.
doi:10.1186/1757-1626-1-286
PMCID: PMC2584083  PMID: 18973682
10.  The Rapunzel Syndrome: An Unusual Trichobezoar Presentation 
Case Reports in Medicine  2010;2010:841028.
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 the hair), consequently developing gastric bezoars. The principal symptoms are vomiting and epigastric pain. In this case report, we describe this syndrome in a young girl.
doi:10.1155/2010/841028
PMCID: PMC2846351  PMID: 20368785
11.  Management of trichobezoar: case report and literature review 
Pediatric Surgery International  2010;26(5):457-463.
Trichobezoars (hair ball) are usually located in the stomach, but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome). They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. In the literature several treatment options are proposed, including removal by conventional laparotomy, laparoscopy and endoscopy. We present our experience with four patients and provide a review of the recent literature. According to our experience and in line with the published results, conventional laparotomy is still the treatment of choice. In addition, psychiatric consultation is necessary to prevent relapses.
doi:10.1007/s00383-010-2570-0
PMCID: PMC2856853  PMID: 20213124
Trichobezoar; Trichotillomania; Rapunzel syndrome; Therapy
12.  An Unusual Case Report of Rapunzel Syndrome Trichobezoar in a 3-Year-Old Boy 
Rapunzel Syndrome is a rare trichobezoar, involving strands of swallowed hair extending as a tail through the duodenum, beyond the stomach. Trichobezoar usually occur in patients with history of trichotillomania, characterized by compulsive behavioral disorder of pulling own hairs, combined with trichophagia that consists of ingesting that hairs. It typically occurs in stomach and rarely affects the small intestine. Trichobezoars are more common in adolescent females. Common presentation is gastrointestinal tract obstruction with nausea and vomiting, gut perforation, acute pancreatic necrosis, obstructive jaundice, hypochromic anemia, vitamin B12 deficiency, weight loss, an abdominal mass, or other serious problems. Intestinal obstruction due to trichobezoar is extremely rare. We are here reporting a large trichobezoar in a 3-year-old male child who presented to the emergency department with thread protruding from mouth with no sign of hair loss on body.
doi:10.4103/0974-7753.90820
PMCID: PMC3250004  PMID: 22223971
Rapunzel; trichobezoar; trichotillomania
13.  Endoscopic retrieval of a gastric trichobezoar 
A 9-year-old girl presented with a chief complaint of abdominal pain. Esophagogastroduodenal endoscopy (EGD) identified a long and large gastric trichobezoar extending into the duodenum. We attempted endoscopic retrieval after informed consent was obtained from the patient’s mother. Initially, a gasper with 5-prolongs, commonly used for retrieval of endoscopically excised polyps, failed to remove the whole trichobezoar. When a net was used instead, it proved impossible to remove the trichobezoar completely. Therefore, we withdrew the scope from the mouth, leaving the net grasping the tricobezoar firmly in the stomach. Subsequently, we were able to retrieve about 70% of the trichobezoar manually by grasping the snare part of the net directly. A second pass found no deep laceration or perforation endoscopically. The remaining trichobezoar was completely retrieved with the net. The procedure was completed within 15 min. The retrieved specimens were 34 cm in length and 100 g in weight. The patient was discharged uneventfully 5 d thereafter. She was advised to visit a psychiatrist to avoid suffering from a relapse. Follow-up EGD showed no trichobezoar, and the patient’s frontal hair grew back.
doi:10.4253/wjge.v3.i1.20
PMCID: PMC3024478  PMID: 21258603
Gastric bezoar; Trichobezoar; Endoscopic retrieval; Grasper; Retrieval net
14.  Trichophagia and Trichobezoar: Case Report 
Objective:
Trichobezoar consists of a compact mass of hair occupying the gastric cavity to a various extent. When the trichobezoar extends past the duodenum it is better referred to as Rapunzel Syndrome. Although trichobezoars are well described in terms of surgical diagnostic and procedure, there are only but very scarce reports on psychiatric literature, usually associated with trichotillomania. The authors present a clinical case of trichobezoar and discuss the most relevant aspects concerning this entity.
Methods:
Presentation of psychiatric and surgical data concerning the case report. Previously reported cases are also mentioned.
Results:
Report of a 27-year-old female patient with a trichobezoar submitted to surgical removal, with a prior intervention 4 years before also due to trichobezoar, and with unknown psychiatric antecedents or follow-up.
Conclusions:
A trichobezoar represents a serious surgical condition. It is important to consider such diagnosis in face of suggestive symptoms, even if signs of trichotillomania are not present. The discrepancies between the prevalence of trichotillomania and trichobezoars due to trichophagia may be due to issues related to self-selection of patients and symptom severity. Such issues may also be important in the study of impulsive-compulsive spectrum models and to their relevance to impulse control disorders.
doi:10.2174/1745017901208010043
PMCID: PMC3367296  PMID: 22675398
Trichobezoar; Rapunzel Syndrome; Trichotillomania; Trichophagia.
15.  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.
doi:10.4240/wjgs.v5.i10.282
PMCID: PMC3812444  PMID: 24179628
Rapunzel syndrome; Trichobezoar; Trichotillomania; Intussusception
16.  'Rapunzel syndrome' trichobezoar in a 7-year-old girl: a case report 
Cases Journal  2008;1:205.
Background
Rapunzel syndrome is a rare type of trichobezoar with an extension of the hair into the small bowel. Clinical presentation is deceptive and vague ranging from abdominal mass to gastrointestinal symptoms.
Case presentation
We present a 7 years old girl with Rapunzel syndrome, where the trichobezoar was not suspected at all especially with negative history of trichophagia. In majority of the cases the diagnosis was made very late in the history of the disease, at a stage where surgery is the only cure for this syndrome.
Conclusion
In the paediatric age group with a long history of gastrointestinal symptom, endoscopy is a diagnostic as well as a therapeutic modality and may reduce surgery in trichobezoars.
doi:10.1186/1757-1626-1-205
PMCID: PMC2567304  PMID: 18831761
17.  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.
doi:10.7860/JCDR/2014/8145.4151
PMCID: PMC4003628  PMID: 24783123
Trichobezoar; Small intestinal obstruction
18.  Gastric outlet obstruction due to duodenal bezoar: A case report☆ 
INTRODUCTION
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by abdominal pain and postprandial vomiting. Causes of GOO include both benign and malignant disease. Bezoars, concretions of undigested or partially digested material in the gastrointestinal tract, are a rare entity and GOO due to duodenal bezoar is an uncommon presentation.
PRESENTATION OF CASE
We report the case of a 56-year-old woman who presented to the emergency department acutely with a 3-day history of epigastric pain, weakness and postprandial nonbilious vomiting. Initially, an upper gastrointestinal endoscopy (UGE) was performed to evaluate the cause of the GOO. A solid impacted bezoar was detected in the first portion of the duodenum with complete obstruction of the pyloric canal. In spite of multiple attempts for fragmentation using different devices, the extraction attempts failed. We administered acetylcysteine and cola per os. Abdominal computerized tomography was obtained and showed a solid mass in the duodenum. UGE was performed once more however, the mass was not suitable for fragmentation and removal. Thus, surgical treatment was decided. The bezoar was extracted via gastrotomy. The postoperative period was uneventful.
DISCUSSION
Even if a duodenal bezoar is small, because of its location it may cause GOO with abruptly clinical features. The diagnostic approach is similar to the other causes of the GOO. However, therapeutic options differ for each patient.
CONCLUSION
We should remember all the therapeutic and diagnostic options for a patient with upper gastrointestinal bezoars who present at the hospital whether or not there is a predisposing risk factor.
doi:10.1016/j.ijscr.2012.07.005
PMCID: PMC3437390  PMID: 22889707
Bezoar; Duodenal bezoar; Endoscopy; Gastric outlet obstruction; Gastrotomy
19.  Gastric trichobezoar associated with transient pancreatitis. 
Archives of Disease in Childhood  1984;59(10):994-995.
A Pakistani girl presented with acute abdominal pain and raised serum amylase and alkaline phosphatase concentrations. She was found to have a gastric trichobezoar with a tail extending to the mid-ileum. The altered biochemical parameters returned to normal after surgical removal of the bezoar. Irritation of ampulla of Vater by the bezoar tail is believed to have caused transient pancreatitis.
Images
PMCID: PMC1628880  PMID: 6497439
20.  Rapunzel Syndrome Case Report: A 13-year-old Girl 
Bezoars are masses, which are commonly encountered in patients after stomach surgery or in those with psychiatric problems, formed by the accumulation of intraluminal nondigestible substances that can lead to obstruction of the stomach and the small intestine. The anatomical changes in the gastrointestinal tract are known to cause bezoar formation. In the absence of an anatomical change, psychiatric disorders such as trichotillomania may lead to the formation of trichobezoars in the stomach. The so-called Rapunzel syndrome is the extension of the bezoars down to the duodenum and the jejunum, which is a rare condition. In this paper, a 13-year-old patient with trichotillomania is reported, who was admitted to our clinic with nausea, vomiting, and fatigue complaints, in whom a giant trichobezoar was identified, which completely filled the stomach and duodenum, without causing obstruction.
doi:10.4103/0974-7753.111202
PMCID: PMC3681111  PMID: 23766614
Rapunzel syndrome; trichobezoar; trichotillomania
21.  Cotton Bezoar- a rare cause of intestinal obstruction: case report 
BMC Surgery  2003;3:5.
Background
Bezoars usually present as a mass in the stomach. The patient often has a preceding history of some psychiatric predisposition. Presentation could be in the form of trichophagy followed by trichobezoar (swallowing of hair leading to formation of bezoar), orphytobezoar (swallowing of vegetable fibres). Rapunzel syndrome is a condition where the parent bezoar is in the stomach and a tail of the fibres or hair extends in to the jejunum. Presentation as intestinal obstruction due to a bezoar in the intestine without a parent bezoar in the stomach is rare, therefore we report it here.
Case report
A 35 year old lady tailor with a previous history of receiving treatment for depression on account of being infertile- years after her marriage, presented to the surgical emergency department with features of acute intestinal obstruction. Exploratory laparotomy and enterotomy revealed a cotton bezoar in the terminal ileum without a parent bezoar in the stomach. She was managed by resection of the affected segment of the ileum and end-to-end anastomosis of the bowel. In the postoperative period the patient gave a history of ingesting cotton threads whenever she was depressed.
Conclusion
Presence of cotton bezoar is rare and an intestinal bezoar in the absence of parent bezoar in the stomach is still rarer.
doi:10.1186/1471-2482-3-5
PMCID: PMC194753  PMID: 12956890
cotton bezoar; ileum
22.  Trichobezoar, gastric polyposis, protein-losing gastroenteropathy and steatorrhoea 
Gut  1973;14(9):730-732.
A mentally subnormal patient presenting with oedema was found at gastroscopy to have a large trichobezoar and multiple gastric polyps. The serum concentrations of albumin and IgG were low in the absence of proteinuria, and the gastrointestinal clearance of radiochromium after the intravenous administration of radiochromic chloride was increased. These findings are compatible with increased gastrointestinal loss of plasma proteins. In addition, the patient had steatorrhoea. All of these abnormal findings were markedly improved after operative removal of the bezoar.
Images
PMCID: PMC1412772  PMID: 4752037
23.  A Large-Sized Phytobezoar Located on the Rare Site of the Gastrointestinal Tract 
Clinical Endoscopy  2013;46(4):399-402.
Bezoars are concretions of undigested material and are most often observed in the stomach. They can occur at any site in the gastrointestinal tract; however, duodenal localization is very rare. We report the case of a 71-year-old male who had undergone subtotal gastrectomy with gastroduodenostomy and experienced severe epigastric discomfort, abdominal pain, and vomiting for a few days. An approximately 7×8 cm-sized mass was found on an abdominal computed tomography scan. On following endoscopy, a large bezoar was revealed in the duodenum and was removed using an endoscopic removal technique, assisted by a large amount of Coca-Cola infusion.
doi:10.5946/ce.2013.46.4.399
PMCID: PMC3746147  PMID: 23964339
Endoscopy; Gastrectomy; Phytobezoar
24.  Esophageal and small bowel obstruction by occupational bezoar: report of a case 
BMC Gastroenterology  2003;3:13.
Background
Phytobezoar may be a cause of bowel obstruction in patients with previous gastric surgery. Most bezoars are concretions of poorly digested food, which are usually formed initially in the stomach. Intestinal obstruction (esophageal and small bowel) caused by an occupational bezoar has not been reported.
Case presentation
A 70-year old male is presented suffering from esophageal and small bowel obstruction, caused by an occupational bezoar. The patient has worked as a carpenter for 35 years. He had undergone a vagotomy and pyloroplasty 10 years earlier. The part of the bezoar, which caused the esophageal obstruction was removed during endoscopy, while the part of the small bowel was treated surgically. The patient recovered well and was discharged on the 8th postoperative day.
Conclusions
Since occupational bezoars may be a cause of intestinal obstruction (esophageal and/or small bowel), patients who have undergone a previous gastric surgery should avoid occupational exposures similar to the presented case.
doi:10.1186/1471-230X-3-13
PMCID: PMC165420  PMID: 12795814
25.  Trichobezoar gastrique - à propos de deux cas 
Abstract
Le trichobezoar gastrique est une affection rare (un peu plus d’une dizaine de cas dans la littérature), qui affecte essentiellement des jeunes filles perturbées par des désordres psychologiques. Les auteurs rapportent deux cas de jeunes filles, hospitalisées pour volumineuse masse épigastrique. La fibroscopie gastrique a posé le diagnostic de trichobezoar. Une exérèse chirurgicale a été réalisée à travers une gastrotomie, sans complications. Un suivi psychiatrique des deux patientes a été recommandé. Le trichobezoar gastrique désigne l'accumulation inhabituelle de cheveux au niveau de l’estomac. Son diagnostic est facile en présence d’un contexte de trichophagie évocateur. La fibroscopie œsogastroduodénale est l’examen de référence permettant la visualisation du trichobezoar dont le traitement est essentiellement chirurgical.
PMCID: PMC3120990  PMID: 21734926
Trichobezoa; Trichophagie; Gastrique; Exérèse chirurgicale; Maroc

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