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1.  Trichophagia along with trichobezoar in the absence of trichotillomania 
Trichobezoars are rarely described in the absence of trichotillomania. In this report we present a case of trichobezoar associated with trichophagia in the absence of trichotillomania. A 16-year-old girl presented to surgery outpatient with complaints of pain in abdomen and vomiting for the last 6 months. Physical examination revealed a 14 × 16 cm firm, tender, mass with smooth surface, irregular margins, which was mobile with respiration. Ultrasound abdomen revealed a bizarre lesion in the right upper and middle abdomen suggestive of gastric bezoars. Upper gastrointestinal endoscopy did not reveal any abnormality in the esophagus and showed a large mobile mass in the stomach. In view of trichobezoar, psychiatry consultation was sought. Exploration of history revealed that the patient was eating hairs and clay since early childhood. As per patient she would eat hairs thrown by others. She would like the taste of hair and had strong persistent desire to eat hair and would go out searching for the same. At times she would also eat clay. However, she denied of pulling her own hairs. Physical examination of scalp and other body parts did not show any evidence of alopecia or pulling of hair/short hair. She was managed surgically and was counseled about the consequences of eating hairs and clays and was encouraged not to eat hair. To conclude our case suggests that patients can have trichobezoar and trichophagia even in the absence of trichotillomania.
PMCID: PMC4271385  PMID: 25540542
Trichophagia; trichotillomania; trichobezoar
2.  Trichobezoar presenting with the 'comma sign' in Rapunzel Syndrome: a case report and literature review 
Cases Journal  2008;1:286.
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.
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.
PMCID: PMC2584083  PMID: 18973682
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.
PMCID: PMC3114431  PMID: 21687591
4.  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.
PMCID: PMC3250004  PMID: 22223971
Rapunzel; trichobezoar; trichotillomania
5.  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
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.
PMCID: PMC3195161  PMID: 22021959
Rapunzel; syndrome; female; giant; trichobezoar
7.  Unusual cause of gastric outlet obstruction: giant gastric trichobezoar: a case report 
Cases Journal  2008;1:399.
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.
There were no complications postoperatively and the patient was referred to a psychiatrist.
PMCID: PMC2634769  PMID: 19087240
8.  'Rapunzel syndrome' trichobezoar in a 7-year-old girl: a case report 
Cases Journal  2008;1:205.
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.
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.
PMCID: PMC2567304  PMID: 18831761
9.  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.
PMCID: PMC3083501  PMID: 21528095
Obstruction; Bezoar; Trichobezoar; Trichotillomania
10.  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.
PMCID: PMC4003628  PMID: 24783123
Trichobezoar; Small intestinal obstruction
11.  Gastric trichobezoar associated with perforated peptic ulcer and Candida glabrata infection 
Bezoars are accumulations of human or plant fiber located in the gastrointestinal tract of both humans and animals. Patients remain asymptomatic for several years, and the symptoms develop as these accumulations increase in size to the point of obstruction or perforation. We report the case of a 21-year-old patient at 10 d postpartum, who presented with acute abdomen associated with sepsis. Given the urgency of the clinical picture, at no point was the presence of a giant bezoar at gastric level suspected, specifically a trichobezoar. The emergency abdominal and pelvic ultrasound revealed only unspecific signs of perforated hollow viscus. Diagnosis was therefore made intraoperatively. A complete gastric trichobezoar was found with gastric perforation and secondary peritonitis. The peritoneal fluid culture revealed Candida glabrata.
PMCID: PMC4266844  PMID: 25516871
Bezoar; Postpartum period; Acute abdomen
12.  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.
PMCID: PMC3921519  PMID: 24574811
Celiac disease; Trichobezoar; Trichotillomania; Behavioral disorder; Malabsorption syndrome
13.  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.
PMCID: PMC2856853  PMID: 20213124
Trichobezoar; Trichotillomania; Rapunzel syndrome; Therapy
14.  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.
PMCID: PMC3024478  PMID: 21258603
Gastric bezoar; Trichobezoar; Endoscopic retrieval; Grasper; Retrieval net
15.  Trichobezoars in baboons 
Journal of medical primatology  2009;38(5):302-309.
There is little information available concerning trichobezoars in the nonhuman primate literature.
We evaluated 118 cases of trichobezoar in baboons over a 29 year period at the Southwest National Primate Research Center.
The anatomic locations affected in decreasing order were the stomach, small intestine, cecum, esophagus, and colon. The most common clinical history was weight loss. The most frequent associated pathology included gastrointestinal inflammation and ulceration, emaciation, peritonitis, intussusception, pneumonia, and aspiration. Trichobezoars were the cause of death in 9 baboons and the reason for euthanasia in 12. Females were 2.14 times more likely than males to be affected. The greater the percentage of group housing time, the more likely the baboon was to develop trichobezoars.
The baboon may present a useful model to evaluate the etiology, genetic predisposition, physiopathology, neurobiology, and treatment response of trichobezoars.
PMCID: PMC2754115  PMID: 19457157
Stomach; hairball; trichophagia; trichotillomania; hair pulling; nonhuman primate; Papio
16.  A modified minimally invasive technique for the surgical management of large trichobezoars 
Trichobezoar which were traditionally managed by open surgical retrieval are now often managed by minimally invasive surgical approach. Removal of a large trichobezoar by laparoscopy, however, needs an incision (usually 4-5 cm in size) for specimen removal and has the risk of intra-peritoneal spillage of hair and inspissated secretions.
The present paper describes a modified laparoscopy-assisted technique with temporary gastrocutaneopexy for the effective removal of a large trichobezoar using a camera port and a 4-5 cm incision (which is similar to that needed for specimen removal during laparoscopy).
Three patients with large trichobezoar were managed with the described technique. The average duration of surgery was 45 (30-60) min and the intraoperative blood loss was minimal. There was no peritoneal spillage and the trichobezoar could be retrieved through a 4-5 cm incision in all patients. All had an uneventful recovery and at a median followup of 6 months had excellent cosmetic and functional results.
The described technique is a minimally invasive alternative for trichobezoar removal. There is no risk of peritoneal contamination and the technical ease and short operative time in addition to an incision limited to size required for the specimen removal, makes it an attractive option.
PMCID: PMC3630719  PMID: 23626422
Limited incision; trichobezoar; bezoar; laparoscopy; trichotillomania; rapunzel syndrome; gastric; hair ball
17.  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.
PMCID: PMC1628880  PMID: 6497439
Indian Journal of Psychiatry  2001;43(4):340-341.
A rare case of 13 years old female child with recurrent trichobezoar stomach which needed reoperation for its removal is reported. Patient also had trichotillomania and mental retardation. She showed satisfactory response to therapy with fluoxetine.
PMCID: PMC2956244  PMID: 21407883
Trichobezoar; trichotillomania; fluoxetine
19.  Trichophagia and Trichobezoar: Case Report 
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.
Presentation of psychiatric and surgical data concerning the case report. Previously reported cases are also mentioned.
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.
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.
PMCID: PMC3367296  PMID: 22675398
Trichobezoar; Rapunzel Syndrome; Trichotillomania; Trichophagia.
20.  Unusual trichobezoar of the stomach and the intestine: a case report 
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.
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.
PMCID: PMC3946194  PMID: 24580892
Bezoar; Endoscopy; Iraq; Laparoscopy; Mass; Rapunzel syndrome; Trichobezoar; Trichotillomania
21.  Intussusception caused by dried apricot: A case report 
An unusual cause of intussusception due to small bowel obstruction secondary to dried apricot consumption was encountered. Phytobezoar small bowel obstruction is a rare, but interesting pathology that accounts for 2–4% of small bowel obstructions (18). Even rarer, is an intussusception caused by dried fruit ingestion. We present the case of a 56-year-old female that presented with an intussusception after she ingested a large amount of dried apricots.
The patient is a 56-year-old female with a small bowel obstruction secondary to intussusception in the distal ileum. She was taken to the operating room for a celiotomy where an intussusception of the distal small bowel was found. An enterotomy was performed which revealed dried apricots as the lead point. The intussusception was successfully reduced and the apricots removed.
Small bowel obstruction due to intussusception can be caused secondary to malignancy, Meckel's Diverticulum, benign neoplasm, and strictures. A less common cause for small bowel obstruction due to intussusception in adults is secondary to mechanical obstruction by bezoars. Risk factors for bezoar formation include previous gastric surgery, diabetes, and mastication problems.
Bezoars are an extremely rare cause of intussusception in adults. A high level of suspicion needs to exist in the presence of a history of eating dried fruit, history of gastric surgery, diabetes mellitus, and problems with mastication. Various treatment modalities exist to treat obstructions secondary to bezoars, including open reduction and removal of bezoar via enterotomy.
PMCID: PMC4276074  PMID: 25437689
Phytobezoar; Small bowel obstruction; Intussusception; Bezoar; Dried apricot
22.  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.
PMCID: PMC2846351  PMID: 20368785
23.  Torsion of Meckel's diverticulum as a cause of small bowel obstruction: A case report 
Axial torsion and necrosis of Meckel’s diverticulum causing simultaneous mechanical small bowel obstruction are the rarest complications of this congenital anomaly. This kind of pathology has been reported only eleven times. Our case report presents this very unusual case of Meckel’s diverticulum. A 41-year-old man presented at the emergency department with complaints of crampy abdominal pain, nausea and retention of stool and gases. Clinical diagnosis was small bowel obstruction. Because the origin of obstruction was unknown, computer tomography was indicated. Computed tomography (CT)-scan revealed dilated small bowel loops with multiple air-fluid levels; the oral contrast medium had reached the jejunum and proximal parts of the ileum but not the distal small bowel loops or the large bowel; in the right mid-abdomen there was a 11 cm × 6.4 cm × 7.8 cm fluid containing cavity with thickened wall, which was considered a dilated bowel-loop or cyst or diverticulum. Initially the patient was treated conservatively. Because of persistent abdominal pain emergency laparotomy was indicated. Abdominal exploration revealed distended small bowel loops proximal to the obstruction, and a large (12 cm × 14 cm) Meckel’s diverticulum at the site of obstruction. Meckel’s diverticulum was axially rotated by 720°, which caused small bowel obstruction and diverticular necrosis. About 20 cm of the small bowel with Meckel’s diverticulum was resected. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day. We recommend CT-scan as the most useful diagnostic tool in bowel obstruction of unknown origin. In cases of Meckel’s diverticulum causing small bowel obstruction, prompt surgical treatment is indicated; delay in diagnosis and in adequate treatment may lead to bowel necrosis and peritonitis.
PMCID: PMC4208045  PMID: 25346803
Meckel’s diverticulum; Axial torsion; Gangrene; Bowel obstruction; Emergency surgery
24.  Giant Trichobezoar of Duodenojejunal Flexure: A Rare Entity 
Bezoars are concretions of undigested material in the gastrointestinal tract, most commonly in the stomach. Duodenojejunal localization of bezoars is exceptional. We report a case of a 27-year-old woman who experienced nausea, vomiting and severe abdominal pain for one week. By palpation a mobile and sensitive mass, 15 × 15 cm, was detected, which filled the upper quadrant. Results of gastric endoscopy were normal. X-ray and ultrasonography suggested a bezoar. A laparotomy revealed that the jejunum was fissured by the trichobezoar ball. This trichobezoar mass was totally excised by intestinal resection.
To our knowledge, this is the first reported case of duodenojejunal fissuration caused by trichobezoar in an adult. Among patients with high subocclusif syndrome, duodenojejunal bezoar should remain a possibility in differential diagnosis.
PMCID: PMC3003208  PMID: 20616419
Duodenojejunal flexure; intestinal partial obstruction; surgery; trichobezoar
25.  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.
We report the case of a large symptomatic trichobezoar with Rapunzel syndrome that occurred in a 17-year-old girl who had trichotillomania.
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.
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.
PMCID: PMC3043579  PMID: 20932380
Trichobezoar; Gastric outlet obstruction; Rapunzel syndrome; Trichotillomania

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