A Rare Case of Rapunzelʼs Syndrome (Trichobezoar)

Abstract

A 29 year old African American female presented to the ER complaining of progressively worsening epigastric pain and N/V over a three month period. She was previously healthy and her physical examination was normal. A CT scan of the abdomen showed only a large volume of retained gastric contents. She was admitted to the surgery service for suspected gallbladder disease. Further evaluation showed evidence of biliary sludge and a gallblader EF of 30%. A gastroenterology consultation was obtained to exclude other potential GI related disorders prior to planned laparoscopic cholecystectomy. Upper Endoscopy showed a large trichobezoar extending from the gastroesophageal junction, filling the entire lumen of the stomach, and extending to the second portion of the duodenum. An overtube and foreign body forceps were utilized in an attempt to remove the trichobezoar, but was unsuccessful due to its size. The trichobezoar was subsequently removed surgically and the patient made an uneventful recovery. It measured 25 cm by 15 cm with a 15 cm duodenal tail (Figures 1 and 2). Trichobezoars are rarely encountered in adult gastroenterology practice. They are formed by swallowed hair (trichophagia). Trichotillomania and trichophagia result from an underlying psychiatric disorder. Most cases are discovered in the pediatric population. Hair material is not digested by the stomach and tends to tangle rapidly forming a bezoar. When the trichobezoar extends beyond the stomach into the small intestine, it is referred to as Rapunzel's Syndrome. Options are very limited for endoscopic removal. Small trichobezoars have been removed with the aid of various forceps and Nd:YAG laser. Larger trichobezoars are better approached surgically, and carry a low morbidity. [figure 1][figure 2]FigureFigure