Rapunzel syndrome causing partial gastric outlet obstruction requiring emergency laparotomy

Abstract

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.

Acute Presentation of Rapunzel Syndrome and a Review of Bezoars

“…The extension of trichobezoars into the cecum and ascending colon as shown in our patient's abdominal X-ray supports the diagnosis of Rapunzel Syndrome. Other complications include bowel obstruction, perforation, intussusception, malnutrition, haematemesis and obstructive jaundice [1][2][3]5].…”

“…The clinical presentation of trichobezoars is associated with its size and presence of complications [ 3 ]. 33 to 37% of the patients present with common symptoms like abdominal pain, nausea and vomiting while some patients may remain asymptomatic for years [ 3 , 5 , 7 ].…”

“…The clinical presentation of trichobezoars is associated with its size and presence of complications [ 3 ]. 33 to 37% of the patients present with common symptoms like abdominal pain, nausea and vomiting while some patients may remain asymptomatic for years [ 3 , 5 , 7 ]. 85% of the patients demonstrate a well-defined, firm and mobile mass in the epigastrium while 20% may be peritonitic upon physical examination [ 3 , 5 ].…”

“…Bezoar, derived from the Arabic word 'Bazahr', refers to an agglutination of indigestible content in the gastrointestinal tract [1][2][3]. Bezoars have different compositions and can be subdivided into trichobezoar (hair ball), phytobezoar (plant), pharmacobezoar (medicinal preparation), lactobezoar (milk curds) and food bolus [1,[4][5][6].…”

“…Trichobezoars are usually seen in females under the age of 30 and may achieve a mortality rate of 30% if left untreated [ 2 , 7 ]. Trichobezoar is usually secondary to trichotillomania and trichophagia with scalp, eyebrows and eyelashes being the commonest sites [ 3 , 5 ]. Atypical dietary habits, impaired mastication, diabetic gastroparesis, achlorhydria and gastric dysmotility secondary to gastrectomies may also contribute to the formation of trichobezoars [ 1 ].…”