Acute Presentation of Rapunzel Syndrome and a Review of Bezoars

Abstract

Bezoars have different compositions and can be subdivided into trichobezoar, phytobezoar, pharmacobezoar, lactobezoar and food bolus. The reported incidence of bezoar is 0.4% with phytobezoar being the commonest. Rapunzel syndrome is an extremely rare complication when trichobezoar crosses the pylorus to enter the duodenum, ileum and colon. We present the case of a 29-year-old female with a oneweek history of abdominal pain, anorexia, nausea, vomiting, constipation, lethargy and a one-year history of increasing abdominal mass. Physical examination revealed a 20 cm palpable mass extending from the left upper quadrant to the umbilicus. Laboratory investigations demonstrated iron deficiency anemia and CT showed two well-defined foci within the gastric lumen consistent with trichobezoars. She was managed conservatively during her hospital stay and discharged home with a plan for elective laparotomy. We present this case to discuss the management of trichobezoars and to highlight the importance of early recognition of recurrence to avoid severe complications.

Acute Case of Trichobezoar Diagnosed From Computed Tomography and 3D Images: Rapunzel Syndrome Re-examined

“…Smaller trichobezoars may be removed using endoscopy while exploratory laparotomy is the preferred approach for larger bezoars [ 14 ]. Rapunzel syndrome in itself is an indication for exploratory laparotomy since it permits proper examination of the gastrointestinal tract and allows for proper management if there are complications [ 1 ]. The success rate of this approach is close to 100% relative to 75% and 5% for laparoscopy and endoscopy, respectively [ 1 , 19 ].…”

“…Rapunzel syndrome in itself is an indication for exploratory laparotomy since it permits proper examination of the gastrointestinal tract and allows for proper management if there are complications [ 1 ]. The success rate of this approach is close to 100% relative to 75% and 5% for laparoscopy and endoscopy, respectively [ 1 , 19 ]. In our case, the patient underwent successful laparotomy with complete removal of the trichobezoar.…”

“…However, previous studies have suggested biannual abdominal imaging as well as routine ultrasound or upper gastrointestinal endoscopy at the six-, 12-, and 24-month follow-up periods [ 20 ]. In a patient with a history of trichobezoars, symptoms such as weight loss, anemia, or parental concern should prompt early endoscopic evaluation [ 1 ]. Further, adequate behavioral therapy for controlling trichophagia and psychological support is imperative for avoiding recurrence.…”

“…A bezoar is a mass of undigested material in the gastrointestinal tract [ 1 , 2 ]. Bezoars can be further categorized based on their contents.…”

Endoscopic Management of Unusual Bezoar in a Prader-Willi Syndrome Patient

“…Mostly bezoar is located in the stomach, jejunum, and ileum. Some patients can be completely asymptomatic [ 3 ]. Our patient's initial presentation was an aspiration, but then he developed melena, which was a result of a bezoar composed of threads that were adherent to the wall of the esophagus and duodenum, causing ulceration and bleeding.…”