An atypical death from Rapunzel syndrome: a case report.

Trichotillomania is a psychiatric disorder characterized by recurring urges to pulling out hairs, eyelashes, or down in other parts of the body. Trichophagia, which is the urge to ingesting the pulled-out hairs, can cause Rapunzel syndrome, an unusual disorder where gastric trichobezoars can be found in the small intestine. Trichobezoars, amorphous masses composed of undigested food formed by hairs, can obstruct the gastrointestinal tract up to simulating symptoms typical of bowel obstruction. Rapunzel syndrome, named after Grimm's tale, may cause death, especially in the pediatric population, being it seldom over the age of 6; moreover, developing countries and environmental and familiar issues are listed as uncertain risk factors. The present case report deals with the death of a 4-year-old female occurred after lunch and following a series of vomit events; while no traumatic or pathological findings were revealed at the external examination, the autopsy revealed three large trichobezoars localized in the stomach and the small intestine. Despite death was due to gastrointestinal obstruction for multiple trichobezoars and collateral bronchoaspiration of dietary material, histological findings were totally non-specific, meaning that it is sometimes difficult to conclude that death is related to the primary pathological condition.

[Giant Rapunzel syndrome with atypical complication. Report of a case]. / Síndrome de Rapunzel gigante con complicación atípica. Reporte de un caso.

Rapunzel syndrome is an unusual and rare form of gastric trichobezoar that extends into the small intestine. The formation is due to the continuous ingestion of hair which leads to the impaction of the hair along with mucus and food, but it is rare that gastric perforation occurs. We report the case of a female patient of 16 years of age admitted to our institution with a history of depression and clinical symptoms characterized by nausea, severe epigastralgia and pathological loss of weight. The physical examination showed a tense abdomen with a peritoneal reaction. Contrast-enhanced tomography showed a distended stomach with a heterogeneous content that extended to the duodenum, hydro pneumoperitoneum, Douglas sack bottom liquid, and it was decided to perform an exploratory laparotomy. Showed perforation in the anterior face of the stomach which is infrequent, so we proceeded to the extraction of giant trichobezoar with duodenal extension; Evolving favorably, the patient being referred to outpatient controls with psychiatry; Finally, a high endoscopy was performed at 6 months, which evidenced the scar of the surgical procedure.

Rapunzel syndrome with double simultaneous trichobezoar in a teenager: Clinical Case Report. / Síndrome de Rapunzel con doble tricobezoar simultáneo en una adolescente: Reporte de caso.

Resumen: Introduction: Trichobezoars are an intraluminal accumulation of ingested hair. The Rapunzel syndrome refers to the presence of gastric trichobezoars which extend to the small intestine together with trichotillomania and trichophagia, that occur predominantly in psychiatric patients of pediatric age. OBJECTIVE: To analyze the clinical course and resolution of this syndrome in a case report. Likewise, we provide information about the family environment and psycho-emotional context of the patients and help the reader identify similar circumstances in their clinical practice. CASE REPORT: Female 14-year-old patient with history of trichotillomania and trichophagia of two years of evolution, who consulted for epigastric pain associated with weight loss, nausea, and postprandial fullness. During the physical examination, the patient was found to have bald patches in the scalp along with a palpable mass that seemed to be confined to the gastric limits. Imaging studies revealed gastric occupation due to a bezoar formation. The patient was treated surgically with laparotomy and gastrostomy, and two simultaneous trichobezoars were removed from the patient´s stomach and duodenum, the patient also underwent psycho-emotional professional counseling. CONCLUSION: Rapunzel´s syndrome, far for being a merely surgical entity, also requires psychoemotional assessment to prevent it recurrence and limit its severity.

[Gastric tricobezoar: a rare cause of tumoral syndrome and pyloric obstruction]. / Tricobezoar gástrico: una causa poco frecuente de síndrome tumoral y de obstrucción pilórica.

UNLABELLED: A Trichobezoar is a rare tumoral mass of the gastrointestinal tract, formed mainly from the ingestion of hair. It contains also mucus and foods debris. CASE PRESENTATION: A 22 years old female with a 10 years history of surgery secondary to gastric foreign body (trichobezoar), presents with abdominal pain, swelling, nausea and vomiting. Physical examination of the abdomen revealed a palpable mass in the epigastric and left upper quadrant regions. It was also noted areas of alopecia of the scalp. DISCUSSION: Ninety percent of the trichobezoars present in females with a high frequency between 10-19 years. The treatment of bezoars (unless small in size) is mainly surgical. A psychiatric evaluation and follow up is important after surgery hence in most cases there is a psychological disorder that lead to the ingestion of hair.

Trichobezoars in children: therapeutic complications.

Trichobezoars are concretions formed by the accumulation of hair or fibers in the gastrointestinal tract, usually associated with underlying psychiatric disorders in females between 13 and 20 years old. Endoscopy, the gold standard for diagnosis, brings some additional advantages: sample taking, size reducing and, rarely, mass removal. This study shows that endoscopy can cause severe complications resulting in a surgical emergency.

Gastric trichobezoar in the absence of psychosocial stressors: a report of two cases.

Abstract.

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.

Treatment of recurrent Rapunzel syndrome and trichotillomania: case report and literature review.

BACKGROUND: Trichotillomania (obsession with one's hair) was first described in the literature over 100 years ago and was recognized by the American Psychiatric Association as a distinct disorder in 1987. OBJECTIVE: The authors discuss a rare presentation of a case of recurrent Rapunzel syndrome in a 37-year-old woman. METHOD: The authors present a biopsychosocial treatment plan for a therapeutic approach. RESULTS: This patient was unique for her relatively advanced age at onset, the recurrent nature, association with pancreatitis, and the consumption of artificial hair extensions, rather than her own hair. This patient presented with small-bowel obstruction requiring laparotomy. After surgery, she was evaluated by the psychiatric service; after discharge, she removed her hair extensions, continued to take her prescribed medication, attended a psychiatric program, and was monitored by family and friends. CONCLUSION: There are no definitive guidelines for treating trichotillomania. In this case, quetiapine, hair-extension removal, family involvement, and regular follow-up helped with the initial cessation of her hair consumption. Antidepressant treatment helped control the obsession while behavioral therapy and family involvement provided the means for habit-reversal training.

Management of trichobezoar: case report and literature review.

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.

Rapunzel syndrome causing partial gastric outlet obstruction requiring emergency laparotomy.

A 16-year-old girl with a background of childhood trichophagia presented with a 2-day history of epigastric pain and associated anorexia with vomiting. An epigastric mass was palpable on examination. A CT scan revealed an intragastric trichobezoar, extending into the duodenum consistent with Rapunzel syndrome with evidence of partial gastric outlet obstruction and a possible perforation. The patient underwent an urgent laparotomy and extraction of the trichobezoar. The bezoar was removed without complication and no intraoperative evidence of perforation was detected. After an uncomplicated postoperative recovery, she was discharged home with psychiatric follow-up.

Rapunzel and pregnancy.

Rapunzel, the girl with long golden tresses in the fairy tale, inspired Vaughan et al to describe, in 1968, cases of trichobezoar with a long tail causing bowel obstruction as "Rapunzel syndrome." A 22-year-old Egyptian woman had been suffering from episodes of epigastric pain and vomiting throughout her pregnancy and puerperium. After diagnosing pancreatitis, we discovered a trichobezoar in her stomach. In an emergent gastrotomy, she was found to have a gastric trichobezoar with a long tail extending down to her duodenum. This is one of the very few cases of Rapunzel syndrome to be complicated by pancreatitis; to our knowledge, it is the first to be reported postpartum.

[Gastroduodenal Trichobezoar in school age: Case report]. / Tricobezoar gastroduodenal en la edad escolar: Caso clínico.

Bezoar is an accumulation of organic substances in the gastrointestinal tract; trichobezoar refers to the accumulation of hair usually in the stomach and even beyond it (Rapunzel syndrome). The incidence of this condition is extremely rare, 90 % of cases occur in women, and 80 % of these occur in those under 30 years of age and are related to anxiety behaviors and psychiatric disorders. The integral approach in these patients is fundamental, together with the interdisciplinary follow-up, treating the underlying psycho-emotional causes and adequate psychoeducation with the patients and their relatives, in order to reduce the risk of possible recurrences. We present the clinical case of a patient of school age, with a history of physical abuse by her stepfather and subsequent anxious behaviors (trichotillomania and trichophagia).

Los bezoares son acumulaciones de sustancias orgánicas en el tracto gastrointestinal. El tricobezoar hace referencia a la acumulación de cabello, por lo general, en el estómago e incluso más allá de este (síndrome de Rapunzel). La incidencia de esta enfermedad es extremadamente rara; el 90 % de los casos se presentan en las mujeres, y el 80 % de estos ocurren en menores de 30 años y se encuentran relacionados con conductas de ansiedad y trastornos psiquiátricos. El abordaje integral en estos pacientes es fundamental, junto con el seguimiento interdisciplinario, para tratar las causas psicoemocionales subyacentes y realizar una adecuada psicoeducación con los pacientes y sus familiares, para disminuir el riesgo de posibles recidivas. Se presenta el caso clínico de una paciente en edad escolar, con antecedente de maltrato físico por parte de su padrastro y posteriores conductas ansiosas (tricotilomanía y tricofagia).

Endoscopic shaving of hair in a gastric bypass patient with a large bezoar.

Trichotillomania can be associated with the formation of trichobezoars (hair ball) usually located in the stomach. Trichobezoars may lead to complications including bowel obstruction, and perforation. Patients with a history of diabetes, certain psychiatric disorders, prior gastric surgery and poor mastication ability are at an increased risk of developing bezoars. We are presenting a case of patient who suffered from a large, recurrent trichobezoar, who had a history of gastric bypass surgery as well as trichotillophagia. The endoscopic method used to remove the large bezoar will also be discussed. We have reviewed the cases published, in which patients developed bezoars after undergoing gastric bypass surgery. The purpose of this study is to raise awareness among clinicians that patients with certain psychiatric issues who had prior gastric surgeries, are at eminent risk of bezoar formation. A multidisciplinary approach including cognitive behavioural therapy, dietary education and pharmacotherapy should be taken to prevent complications.

[Trichobezoar: presentation of three cases, clinical and psychological profile]. / Tricobezoar: presentación de tres casos, perfil clínico y psicológico.

INTRODUCTION: The description of Trichobezoar is very ancient; it is an occasional entity and it mainly affects young women with deep psychopathology. CASES REPORT: Three cases of teenagers with gastric Trichobezoar have been studied; their clinical evolution and diagnostic methods were analyzed. Their psychological profile and familiar environment were particularly studied in our hospital by gastroenterology and psychology. DISCUSSION: Clinical manifestations are unspecified, however long-evolution dyspepsia is predominant and the diagnosis can be suspected for the young age of the patients, most of them females, with certain atypical personality characteristics with a palpable abdominal mass in the epigastrium in advanced stages of the illness; the most useful diagnosis methods are simple abdominal x-rays, UGI x-rays and endoscopy. Psychological evaluation revealed a familiar dysfunction in all of them. We observed a profile of dysfunctional personality in different degrees, including psychomotor retardation in two of them. All of the cases were solved surgically without complications. The last two cases, as well as their parents have received family psychotherapy, and now the evolution is favorable. Control endoscopies were made 6 months after the surgical event and do not show any trace of hair in the stomach.

Laparoscopic removal of a large gastric trichobezoar.

A large trichobezoar has been traditionally removed by open surgery, which has entailed an upper abdominal incision. With the advent of laparoscopic surgery, it became feasible to retrieve a foreign body from the stomach without the necessity of a large skin incision in the upper abdomen. A 7-year-old girl presenting with abdominal pain, nausea, and appetite loss was admitted and evaluated. Results of an upper gastrointestinal series showed a large mass in the stomach that extended into the duodenum. Endoscopical removal had been tried twice under general anesthesia and resulted only in the retrieval of the small portion of the trichobezoar in the duodenum; total removal seemed impossible with endoscopic techniques. Laparoscopic removal was then under-taken to avoid the surgical scar in the upper abdomen. The trichobezoar was successfully retrieved through a gastrotomy and removed via a small suprapubic incision. This approach may be the treatment of choice for future cases of trichobezoar when surgery is indicated.

Empacho in four Latino groups: a study of intra- and inter-cultural variation in beliefs.

It is usually impossible to know if reported differences between cultures are due to cultural differences or due to a difference in the methods used to study the cultures. This paper describes a collaborative, multisite study using a shared methodology to study intra- and inter-cultural variation in beliefs. A series of standard interview schedules were used to study Latin American beliefs about empacho in Guatemala, Mexico, and in the United States (Mexican-Americans and Puerto Ricans). Results showed consistency in beliefs about empacho both within and between the four samples.

Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department.

Abdominal pain is a common presenting complaint of children seen in urgent care settings. It is the manifestation of a wide variety of disease processes ranging from benign to immediately life-threatening. Gastric bezoars are among the etiologies of chronic childhood abdominal pain that, when undiagnosed, may result acutely in serious complications, including gastric ulceration, bleeding and perforation, intussusception, and small bowel obstruction. To reinforce the importance of including this entity in the differential diagnosis of abdominal pain, we present the case of a 10-year-old girl with a history of chronic epigastric complaints who was ultimately presented with acute small bowel obstruction following fragmentation and distal migration of her gastric trichobezoar. Finally, we review and briefly summarize the current literature regarding the etiology, diagnosis, and management of this disorder in children.

Recurrent gastric trichobezoar.

Trichobezoars are concretions of ingested hair that are found in the stomach. Recurrence of this condition has not been reported. We report an 18-year-old girl with recurrent trichobezoar; this emphasizes the need for counseling in these patients.

Trichotillomania resulting in a trichobezoar: a case report.

This paper presents a case of a 19-year-old, 10 1/2-week-pregnant woman with trichotillomania that resulted in a trichobezoar. The case illustrates typical presentation, patient behavior, symptomatology, and physical findings of patients with trichobezoars. The hypothesized methods for trichobezoar formation, complications, and treatment are discussed. The diagnostic criteria, epidemiology, and treatment of trichotillomania are also discussed.