History Of Trichotillomania Research Articles

Rapunzel syndrome debuts as a gastric perforation

Rapunzel syndrome refers to a rare disease that consists of a variant of gastric trichobezoar that has an extension distal to the small bowel. Most cases occur in young women with an underlying psychiatric illness, such as trichotillomania and trichophagia. The trichobezoar should be considered as a differential diagnosis of abdominal pain in young patients with the presence of associated psychiatric pathology since its early diagnosis allows avoiding complications. We present the case of Rapunzel syndrome in a young female patient with no documented history of trichotillomania or trichophagia who presented with gastric perforation. The patient underwent surgery, and a 25 cm trichobezoar was extracted from the stomach. She was discharged home on the 3rd postoperative day. Multidisciplinary management with general surgery, gastroenterology, and psychiatry divisions is essential for offering an integrative treatment to these patients.

Rapunzel syndrome associated with giant trichobezoar in a patient with a history of trichotillomania: case report

We present the clinical case of an 18-year-old female patient with a personal history of onychophagia, trichophagia, trichotillomania and anxiety disorder with poor adherence to treatment. She presented at the Emergency Department with clinical data compatible with intestinal obstruction at the gastric level with presence of an abdominal mass in the upper quadrant accompanied with a three-day history of abdominal pain, vomit and absence of bowel movements. A simple abdominal tomography was performed, showing gastric outlet obstruction with material suggestive of bezoar and small bowel dilatation. An urgent laparotomy was performed finding a giant trichobezoar with measurements of 30x12x6 centimeters. Patients affected by trichobezoars usually remain asymptomatic for many years and the onset of symptoms is insidious. The most associated symptoms include abdominal pain, nausea, vomiting, early satiety, anorexia and weight loss, as well as clinical data compatible with gastric obstruction. Trichobezoar is an extremely rare entity, with an incidence of less than 0.3% of the general population, occurring almost exclusively in female patients with a history of trichotillomania.

Rapunzel syndrome: an uncommon tale of a long hairy tail - case report and review of literature

Trichobezoar is a rare clinical entity in which a ball of hair accumulates within the alimentary tract. When the tail of the trichobezoar extends into the small intestine, this condition is called Rapunzel syndrome (RS). A 14-year-old female presented with pain abdomen and vomiting for 2 weeks, and a history of trichotillomania and trichophagia, and an epigastric lump. A contrast enhanced computerized tomography (CECT) of the abdomen showed a grossly distended stomach with a heterogeneous mass containing trapped air with underlying normal mucosa suggestive of trichobezoar, with its tail extending into the proximal jejunum suggestive of RS. During laparotomy, a giant trichobezoar was seen in the stomach with its tail extending beyond the duodenum into the proximal jejunum. The entire specimen was delivered out intact. On follow up, she has no surgical complications, and was on behaviour therapy. Trichobezoars form when ingested hair strands become retained in the folds of the gastric mucosa and becomes entangled, forming a ball too large to exit the stomach. Trichotillomania and trichophagia are seen in many of these patients. Patients present with abdominal pain, vomiting, gastric outlet obstruction, and an epigastric mass. In the case of RS, complete removal without breakage and distal migration is important. RS should be considered as a differential diagnosis in a young girl with abdominal pain, vomiting, anaemia and upper abdominal lump. Early diagnosis prevents complications. Surgical removal is treatment of choice. Trichobezoar often coexists with psychiatric illness. Psychiatric evaluation, counselling and treatment are helpful in preventing recurrence.

Trichobezoar: a rare clinical rendezvous with twin sisters

Trichobezoar is very uncommon in the pediatric age group. Till now no familial predisposition has been reported. We hereby report our clinical experience with eight years old twin sisters one of whom had a huge gastric trichobezoar and other one had a history of trichotillomania with recurrent vomiting and weight loss. An eight years old female child, one of the twin, presented with history of recurrent vomiting. Abdominal examination revealed firm mass in epigastric region. X-ray abdomen showed the transverse colon pushed down. Ultrasonography revealed echogenic mass in the stomach. Preoperative diagnosis of trichobezoar was achieved by a computed tomography (CT) scan. Laparotomy was done through the midline abdominal incision after initial session of resuscitation. A huge mass of hair was retrieved from the stomach part of which was passing into the duodenum. Patient was found to have underlying trichotillomania and obsessive compulsive disorder. As the patient was one of the twins, other sibling was called and evaluated for the mental health. Interestingly, she was found to have trichotillomania and trichophagia. Examination revealed sparse scalp hair. X-ray and the sonography of the abdomen were normal. Patient was advised endoscopic examination which the guardian of the patient refused. Patient was put on outpatient department (OPD) follow up after psychiatric counselling. Trichobezoar should be suspected in a pediatric patient of gastrointestinal symptoms, epigastric mass and anemia with history of trichophagia. Open surgery gives optimum results. Sibling of an affected twin must be evaluated on the similar lines and managed accordingly.

Rapunzel syndrome in an adolescent girl

Bezoars are masses, which are commonly encountered in patients after stomach surgery or in those with psychiatric problems. These are formed by the accumulation of intraluminal non digestible substances that can lead to obstruction of the stomach and the small intestine. Trichobezoars are concretions formed by accumulation of hair in stomach. Usually, trichobezoar is confined to the stomach. However, rarely there is contiguous extension of trichobezoar through the pylorus into jejunum, ileum and even up to the colon. Such a condition is called the Rapunzel syndrome. The term comes from a story written by the Grimm brothers in 1812 about Rapunzel who was a long-haired maiden. Rapunzel syndrome is an extremely rare complication of a gastric trichobezoar. We hereby, present the case of a 13 years old girl with Rapunzel syndrome due to a very large gastric trichobezoar. The patient had trichotillomania and trichophagia for 11 year prior to presentation. An abdominal computed tomography scan showed a heterogeneous mass occupying the whole stomach cavity with extension into the jejunum. She was subjected to an exploratory laparotomy and gastrotomy. A large dense mass of hair extending up to jejunum was removed. Following surgery, psychiatric consultation was sought to prevent recurrence. Cases of trichobezoar have been reported in literature very infrequently but Rapunzel syndrome is extremely rare and less than 50 cases have been reported in medical literature till date. Trichobezoar is a very rare cause of upper abdominal mass and should be considered if there is a history of impulsive hair pulling. A psychiatric assessment and a long-term follow-up are advocated as a regular part of treatment to prevent recurrence. • Trichobezoar leading to Rapunzel syndrome is an extremely rare entity with less than 50 cases been reported in medical literature till date. • It should be considered strongly in a young patient with abdominal pain and non-tender abdominal mass with history of trichotillomania. • The diagnosis is possible on imaging in a proper clinical setting. However, Rapunzel syndrome is most often an intraoperative finding. • Surgical removal is the gold standard treatment of choice. • Parental counselling, neuropsychiatric assessment and treatment, long-term follow-up and behavioural therapy are advocated as a regular part of treatment to prevent recurrence.

Rapunzel syndrome trichobezoar in a twelve year old girl: a case report

A bezoar refers to a mass of undigestible foreign material found in the gastrointestinal tract, mainly stomach. The second most common bezoar is the trichobezoar, which usually occurs in the young psychiatric female patients with history of trichotillomania and trichophagia. A 12-year-old female psychiatric patient came with complains of diffuse abdominal pain, vomiting, fever, and constipation. Ultrasonography and CT scan were done, which suggested trichobezoar. Thus, trichobezoar should be considered as differential diagnosis of abdominal pain in young psychiatric female patients. In the literature several treatment options are proposed, including removal by conventional laparotomy, laparoscopy and endoscopy. 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. We here report a case of 12 years old girl presented with complain of vomiting, pain and lump abdomen, loss of appetite and on laprotomy a large, approximately 156 cm trichobezoar was removed which was extending from stomach to ileocaecal junction. Trichobezoar, an underdiagnosed entity, has to be considered in the differential diagnosis of abdominal pain and a non-tender abdominal mass even in young children.

A Rare Case of Isolated Trichobezoar in Jejunum Presenting as Obstruction - A Case Report

A trichobezoar is a mass formed by ingestion and accumulation of undigested hair inside the gastrointestinal tract. Stomach is the most common site which may extend to duodenum as well as jejunum, which is then referred as Rapunzel Syndrome. Incidence of trichobezoar in paediatric population is around 0.4% [1]. It is seen typically in girls usually with a history of trichotillomania and trichophagia. Affected children may remain unnoticed until it causes obstructive symptoms. We hereby report a unique case of isolated jejunal trichobezoar presenting as intestinal obstruction in an 8yr old girl.

Rapunzel syndrome: how to orient the diagnosis.

Rapunzel syndrome is a rare form of tricobezoar with a tail extending from the stomach into the small bowel; surgical removal is generally required. About 60 cases have been reported and described in the literature since 1968. We present the case of an 8-year-old girl who, during the course of a genetic consultation, was initially assigned with a clinical suspicion of ectodermal dysplasia. Surgical intervention, which resulted in the extraction of a tricobezoar of enormous size and extension, led us to the diagnosis of Rapunzel syndrome. The possibility of a tricobezoar should be considered in all cases of adolescent patients who present signs of intestinal occlusion or sub-occlusion, suffer from psychiatric disorders, and have a history of trichotillomania. Endoscopic methodology, medical imaging and clinical diagnostics are fundamental for a differential diagnosis. Psychiatric follow-up is advised to prevent recurrence.

Plucking, Picking, and Pulling: The Hair-Raising History of Trichotillomania.

Plucking, Picking, and Pulling: The Hair-Raising History of Trichotillomania.

English

Bezoar is a conglomeration of foreign material in the intestinal tract. Trichobezoar (accumulation of hair in the gastric chamber, secondary to impulsive pulling and intake) and Rapunzel syndrome (accumulation of hair in the small intestine) usually occur in children and adolescents with trichotillomania and trichophagia history. We present the case of a 14-year-old female who arrived for consultation. The patient had a 10-month history of intermittent abdominal pain, gastric fullness, nausea, occasional vomiting and weight loss. In addition, she had a history of trichotillomania, trichophagia. Laboratory tests revealed hypochromic microcytic anemia. Ultrasonographic study demonstrated intense sonic shadowing posterior to the gastric area. After performing gastrotomy, the specimen was extracted and consisted of hair that occupied the entire length of the gastric chamber. Post operative recovery of the patient was uneventful. The patient was referred to psychiatric evaluation post operatively.

Compulsive Joint Clicking on the Obsessive-Compulsive Spectrum

To the Editor: Compulsive motor acts are often a challenge in clinical practice. Tics and habit spasm per se are considered neurologic disorders, whereas skin picking and onychophagia are viewed primarily as impulsive neurotic behaviors associated with emotional immaturity. However, both types of behaviors are well known to be associated with obsessive-compulsive disorder (OCD). We add compulsive joint clicking to this spectrum.1 Case report. Ms A, a single woman in her early 20s, presented with severe obsessions and compulsions complicated by depressive symptoms a year after graduation from university. Her obsessions and compulsions were related to checking, searching for symmetry in her environment, and avoidance of anything that men use, wear, or even touch, which was a cause of frequent quarrels with her brothers and father. The latter was precipitated by her witnessing her mother sexually harassed on a public bus in Cairo. She had a past history of trichotillomania and current compulsive onychophagia (biting of fingernails and toenails) of mild severity, compulsive skin picking that led to facial disfigurement, and compulsive joint clicking (mostly the ankle and fingers). She suffered from OCD (DSM-IV-TR criteria) dominated by religious ruminations and blasphemous ideation in childhood and went through a phase of hoarding empty boxes. Behavioral analysis revealed that onychophagia was mostly a response to stressful situations whereas compulsive skin picking was triggered by presence of wounds or furuncles. She complained of being unable to prevent herself from repetitive clicking of her ankle, joints, and fingers. The clicking sometimes lasted for several minutes and was observed to be slow, voluntary, compulsive, and repetitive and triggered by a strange uncomfortable joint feeling that subsided only after the joint was exhausted by repeated clicking. We referred to the latter as “compulsive joint clicking,” and an orthopedic consultation ruled out organic factors. She was successfully treated using combined cognitive-behavioral therapy (CBT) and pharmacotherapy (clomipramine 150 mg, sertraline 50 mg), which led to improvement in depressive symptoms first. Her avoidance of male belongings as well as her searching for symmetry and checking improved at a later date, but compulsive skin picking and compulsive joint clicking responded only to the addition of pimozide 2 mg daily 3 months after the start of CBT and initial pharmacotherapy. The compulsive onychophagia did not change. Her condition remained stable for 4 years. She asked for withdrawal of medication before getting married, which was done during 3 months. She continued to be well a year later. The behavior of the patient was in response to strange uncomfortable joint feeling. She attributed her compulsive behavior to wanting to get rid of this sensation. This case demonstrates the presence of several obsessive-compulsive spectrum behaviors related to skin and appendages such as trichotillomania, onychophagia, and compulsive skin picking. The compulsive joint clicking was different in being slow, voluntary, and repetitive. It is similar to complex motor tics that are defined as intentional movements made in an attempt to diminish uncomfortable sensations.2 Treatment of OCD with double therapy did not influence the behavior, and it was only after the addition of pimozide that the patient noticed marked improvement. We may formulate a spectrum from compulsive motor acts (compulsive but voluntary or intentional to get relief from anxiety or discomfort) to motor tics (impulsive and involuntary and purposeless). Compulsive joint clicking is situated toward the motor tics end of that spectrum.

Gastric tricho-wool bezoar in an 18-year-old girl.

An 18-year-old girl with no psychiatric history presented with abdominal pain. Four months previously she had given birth to a healthy baby. On palpation, a painful abdominal mass was identified in the epigastric region, and gastrotomy was performed. A J-shaped hair-wool ball and two large pieces of sheep's wool were removed. No history of trichotillomania was reported.

An unusual cause of gastric outlet obstruction in a young girl: Trichobezoar

Trichobezoars are an infrequent form of bezoars formed from ingested hair. They are more common in adolescent females with history of trichotillomania. Exceptionally, it can occur in young children making the diagnosis difficult. We report the case of a 6-year-old girl with a history of abdominal pain, distension, weight loss, and attacks of vomiting. Upper gastrointestinal endoscopy revealed a trichobezoar occupying almost the whole gastric cavity. The gastric bezoar was removed by surgery. Gastric trichobezoar is exceptional in young children and can lead to stunting and gastric outlet obstruction. After definitive surgical or endoscopic treatment, pediatric psychiatric consultation should be opted for any mental disorder and for prevention of further recurrence.

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.

Rapunzel Syndrome—A Rare Cause of Multiple Jejunal Intussusception

Trichobezoars are usually without symptoms until they reach a large size. The "Rapunzel" syndrome is a trichobezoar with a long tail extending from the stomach to small bowel. We report the case of a 6-year-old girl with a history of trichotillomania and hair ingestion for three years, who presented with multiple jejunojejunal intussusceptions due to a trichobezoar with a long, 90-cm tail into the small bowel. To our knowledge, this is the first report of trichobezoars as a cause of jejunal intussusceptions, which should be suspected in the appropriate clinical circumstances.

Rapunzel syndrome

View Large Image Figure Viewer View Large Image Figure Viewer View Large Image Figure Viewer A 5-year-old girl presented for recurrent food-related vomiting and a lump in her abdomen of 3 months' duration. There was a history of trichotillomania and trichophagia. On examination, the girl looked pale, and she was depressed. She had bilateral temporal alopecia. On abdominal examination, a mobile, nontender, 6 × 10-cm lump was palpated in the upper abdomen. A barium contrast study showed a filling defect in the stomach (A). CT of the stomach showed a well-defined cast with a mottled shadow because of trapped air (B). The contrast lined the mass without enhancing it. An upper-GI endoscopy revealed a gastric trichobezoar extending into the duodenum. The mucosa was normal. Endoscopic retrieval was unsuccessful. The trichobezoar was finally removed by an anterior longitudinal gastrotomy (C). It was 6 × 10 cm in size, with a 72-cm-long tail extending into the intestine (D). Hence, a diagnosis of Rapunzel syndrome was kept. The postoperative period was uneventful. On psychiatric evaluation, the patient was found to have an impulse control disorder for which she received treatment. View Large Image Figure Viewer View Large Image Figure Viewer

Self-Monitoring, Competing Response and Response Cost in the Treatment of Trichotillomania: A Case Report

Self-monitoring, a competing response and response cost were used in the successful treatment of a 49 year old female patient with a 19 year history of trichotillomania. Self-monitoring and a competing response produced significant decreases in hair-pulling, but still continued as the patient found it pleasurable at times of stress. The addition of response cost procedures overcame this.

Duodenal trichobezoar caused by compression of the superior mesenteric artery

Trichobezoars can occur in young women who have a history of trichotillomania, trichophagia, gastric dysmotility, and psychiatric dysfunction. A 6-year-old anorexic girl presented with a fixed right-upper-quadrant abdominal mass. Exploratory celiotomy for a duodenal trichobezoar led to removal of the large foreign body, via a duodenotomy, and prompted a Ladd procedure, in which the duodenum was moved from beneath the compressing superior mesenteric artery to relieve underlying duodenal narrowing.