Rapunzel syndrome: an infrequent cause of severe iron deficiency anemia and abdominal pain presenting to the pediatric emergency department.

BACKGROUND: Iron deficiency anemia (IDA) and abdominal pain are commonly seen in a pediatric emergency department (8 and 18% incidence respectively in our center). They are manifestations of a wide variety of diseases ranging from benign to immediately life-threatening. Trichobezoar is an under-diagnosed entity that has to be considered in children and adolescents, expecially female, suffering from trichotillomania (compulsion to pull hair) and trichophagy (compulsion to swallow hair). When undiagnosed, gastric bezoars may cause gastric ulceration, perforation, haemorrhage and obstruction. CASE PRESENTATION: To underline the importance of including this pathology in the differential diagnosis of IDA and abdominal pain, we present the case of a 14 year-old girl with a huge trichobezoar which completely filled the stomach and extended into the small bowel. Since trichobezoar has an extension to the small bowel, it is classified as Rapunzel syndrome. As the bezoar couldn't be removed by endoscopy, the girl underwent surgical intervention. The patient passed through a gradual re-feeding, with iron and vitamins supplementation, and through a psychiatric counselling. CONCLUSION: The Rapunzel syndrome is a rare entity that may be complicated by life-threatening events. A prompt diagnosis and an appropriate therapy can reduce comorbidities. Gradual re-feeding with supplementation of micronutrients allows adequate catch-up weight with normalization of haematochemical nutritional parameters. Since many of these patients suffer from psychiatric pathology such as PICA with emotional problems and mental retardation, psychological/psychiatric counselling plays an important role in order to prevent bezoar recurrence.

[The placement of colonic stents in emergency surgery]. / Uso in elezione ed in urgenza delle protesi intestinali.

INTRODUCTION: The treatment for malignant colonic obstruction usually consists in a diverting colostomy. The usefulness colorectal stent to resolve the occlusion is a new interesting application to prevent unnecessary operation. METHODS: From September 1999 to June 2005 73 patent underwent the positioning of colorectal stent for colorectal cancer or extrinsic compression under double fluoroscopic and endoscopic control. In 35 patient the stent was inserted as palliative measure, and 38 underwent stent as bridge to surgery. RESULTS: The placement of the stent was achieved in all patient, with 94% (69/73) of clinical success. Perforation occurred in two patient, one related to the guide wire and the other to balloon dilatation of the stent. Reobstruction occurred in 3 patient and migration in 9. The mortality after stent placement was 4.1% (3/73). We perform a colostomy or an ileostomy in 4 patient bridge to surgery and in 4 palliative, for a total of 8 stoma (10.95%). CONCLUSION: The usefulness of colorectal stent can be consider an alternative to colostomy especially in unresectable patients.