Mallory-Weiss syndrome from giant gastric trichobezoar: A case report

BACKGROUND Mallory-Weiss syndrome(MWS),representing a linear mucosal laceration at the gastroesophageal junction,is a quite frequent cause of upper gastrointestinal bleeding,usually induced by habitual vomiting.The subsequent cardiac ulceration in this condition is likely due to the concomitance of increased intragastric pressure and inappropriate closure of the gastroesophageal sphincter,collectively inducing ischemic mucosal damage.Usually,MWS is associated with all vomiting conditions,but it has also been described as a complication of prolonged endoscopic procedures or ingested foreign bodies.CASE SUMMARY We described herein a case of upper gastrointestinal bleeding in a 16-year-old girl with MWS and chronic psychiatric distress,the latter of which deteriorated following her parents’divorce.The patient,who was residing on a small island during the coronavirus disease 2019 pandemic lockdown period,presented with a 2-mo history of habitual vomiting,hematemesis,and a slight depressive mood.Ultimately,a huge intragastric obstructive trichobezoar was detected and discovered to be due to a hidden habit of continuously eating her own hair;this habit had persisted for the past 5 years until a drastic reduction in food intake and corresponding weight loss occurred.The relative isolation in her living status without school attendance had worsened her compulsory habit.The hair agglomeration had reached such enormous dimensions and its firmness was so hard that its potential for endoscopic treatment was judged to be impossible.The patient underwent surgical intervention instead,which culminated in complete removal of the mass.CONCLUSION According to our knowledge,this is the first-ever described case of MWS due to an excessively large trichobezoar.

Endoscopic retrieval of a gastric trichobezoar

A 9-year-old girl presented with a chief complaint of abdominal pain. Esophagogastroduodenal endoscopy (EGD) identifi ed a long and large gastric trichobezoar extending into the duodenum. We attempted endoscopic retrieval after informed consent was obtained from the patient's mother. Initially, a gasper with 5-prolongs, com monly used for retrieval of endoscopically excised poly ps, failed to remove the whole trichobezoar. When a net was used instead, it proved impossible to remove the trichobezoar completely. Therefore, we withdrew the scope from the mouth, leaving the net grasping the tri co bezoar firmly in the stomach. Subsequently, we were able to retrieve about 70% of the trichobezoar manually by grasping the snare part of the net directly. A second pass found no deep laceration or perforation endoscopically. The remaining trichobezoar was completely retrieved with the net. The procedure was completed within 15 min. The retrieved specimens were34 cm in length and 100 g in weight. The patient was discharged uneventfully 5 d thereafter. She was advised to visit a psychiatrist to avoid suffering from a relapse. Follow-up EGD showed no trichobezoar, and the patient' s frontal hair grew back.

A trichobezoar in a child with undiagnosed celiac disease: A case report

Celiac disease is a chronic, immune-mediated enteropathy caused by a permanent sensitivity to ingested gluten cereals that develops in genetically susceptible individuals. The classic presentation of celiac disease includes symptoms of malabsorption but has long been associated with cognitive, emotional, and behavioral disorders. We describe an 8-year-old patient with nonscarring alopecia and diagnosed with trichotillomania. Furthermore, she presented with a 3-year history of poor appetite and two or three annual episodes of mushy, fatty stools. Laboratory investigations showed a normal hemoglobin concentration and a low ferritin level. Serologic studies showed an elevated tissue immunoglobulin G anti-tissue transglutaminase level. A duodenal biopsy showed subtotal villous atrophy and crypt hyperplasia, and a large gastric trichobezoar was found in the stomach. Immediately after beginning a gluten-free diet, complete relief of trichotillomania and trichophagia was achieved. In this report, we describe a behavioral disorder as a primary phenomenon of celiac disease, irrespective of nutritional status.

Extremely unusual case of gastrointestinal trichobezoar

Trichobezoars(hair ball) are usually located in the stomach, but may extend through the pylorus into the duodenum and small bowel(Rapunzel syndrome). Rapunzel syndrome remains uncommon; with fewer than 40 cases reported. To the best of our knowledge, this case may be the first well-documented case with a length of 75 cm. 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. Herein, we are reporting an interesting case of an 18-year mentally retarded girl with history of trichotillomania and trichophagia who presented to our emergency department with a history of central abdominal pain associated with vomiting and constipation for five days. An examination showed a trichobezoar requiring emergent surgical intervention, and indicating the need for psychiatric treatment. The trichobezoar was treated successfully by laparoscopy.

Giant gastroduodenal trichobezoar: A case report

BACKGROUND We report a case of giant gastroduodenal trichobezoar,an extremely rare upper gastrointestinal bezoar due to trichotillomania and trichophagia.CASE SUMMARY The patient was a 10-year-old girl who presented with an abdominal mass that was discovered at palpation and noninvasive imaging examinations.Computed tomography(CT)showed a well-circumscribed heterogeneous mass extending from the stomach into the duodenum.The patient underwent a laparotomy to pull out the trichobezoar.Although these imaging findings are nonspecific,trichobezoar should be included in the differential diagnosis of gastric mass,especially with the history of an irresistible urge to pull out and swallow their hair.CONCLUSION Laparotomy is useful and practical for the management of giant gastroduodenal trichobezoar.

Trichobezoar:A rare cause of bowel obstruction

A bezoar is an intraluminal mass formed by the accumulation of undigested material in the gastrointestinal tract. A trichobezoar is a bezoar made up of hair and is a rare cause of bowel obstruction of the proximal gastrointes-tinal tract. They are seen mostly in young women with trichotillomania and trichotillophagia and symptoms include epigastric pain, nausea, loss of appetite and bowel or gastric outlet obstruction. We herein describe a case of a trichobezoar that presented as a gastric outlet obstruction and was subsequently successfully removed via a laparotomy.

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.

Gastric Trichobezoar, Case Presentations

Trichobezoars are accumulations of hair casts in the stomach which is associated with trichophagia. The continuous ingestion causes mass of undigested material within the gastrointestinal, accumulating between the mucosal folds of stomach. Trichotillomania, is a mental disorder, described when someone cannot resist the urge to pull their hair from the scalp, eyebrows or eyelashes seen generally by teenagers or adolescents. A person with trichotillomania may experience repetitive pulling of hair, often without awareness, associated with anxiety and a sense of relief after pulling out hair. Consumed hair strands are beyond the pylorus into the small bowel identified as Rapunzel syndrome. Two cases of trichobezoars were encountered in our centre. They presented with nonspecific abdominal pain and abdominal mass. After investigations, with clinical correlation they were subjected to surgery, an open gastrotomy and complete removal of the trichobezoars. After surgery, the aim is to prevent recurrence by tackling the underlying cause of trichophagia which is commonly associated with trichotillomania. This case report series discusses about the management of trichobezoars.

Endoscopic retrieval of gastric trichobezoar after fragmentation with electrocautery using polypectomy snare and argon plasma coagulation in a pediatric patient

Trichobezoars are rare,composed of hair and more common in female pediatric patients with psychiatric disorders.Opensurgical extraction is the most common removal method.Only two endoscopic removals after fragmentation have beenreported in the English literature.We report herein a third case of a trichobezoar that was successfully retrieved afterendoscopic fragmentation with snare polypectomy and argon plasma coagulation in a six-year-old female patient.Thetrichobezoar mass was completely removed in 10 pieces after 15 passes.The patient’s course was uneventful.Nine monthslater,she is doing well.This endoscopic removal was effective,minimally invasive and time saving.

Trichobezoar and Rapunzel syndrome

A 12-year-old girl without a history of psychiatric disorders presented to the emergency department with abdominal pain and mass in epigastric and left upper quandrant.The vital signs and laboratory studies were unremarkable.

Review of the diagnosis and management of gastrointestinal bezoars

The formation of a bezoar is a relatively infrequentdisorder that affects the gastrointestinal system.Bezoars are mainly classified into four types dependingon the material constituting the indigestible mass of thebezoar phytobezoars, trichobezoars, pharmacobezoars,and lactobezoars. Gastric bezoars often cause ulcerativelesions in the stomach and subsequent bleeding,whereas small intestinal bezoars present with smallbowel obstruction and ileus. A number of articles haveemphasized the usefulness of Coca-Cola？ administrationfor the dissolution of phytobezoars. However, persimmonphytobezoars may be resistant to such dissolutiontreatment because of their harder consistency comparedto other types of phytobezoars. Better understanding ofthe etiology and epidemiology of each type of bezoarwill facilitate prompt diagnosis and management.Here we provide an overview of the prevalence, classification,predisposing factors, and manifestations ofbezoars. Diagnosis and management strategies arealso discussed, reviewing mainly our own case series.Recent progress in basic research regarding persimmonphytobezoars is also briefly reviewed.

Gastrointestinal bezoars: A retrospective analysis of 34 cases

AIM: Bezoars (BZ) are the most common foreign bodies of gastrointestinal tract. Clinical manifestations vary depending on the location of BZ from no symptoms to acute abdominal syndrome. When located in small bowel, they frequently cause small bowel obstruction (SBO). We aimed to present our experience by reviewing literature.METHODS: Thirty-four patients with gastrointestinal BZ were presented. The data were collected from hospital records and analyzed retrospectively. Morbidity and mortality rates were statistically analyzed between the subgroups according to SBO and endoscopic or surgical treatment modalities.RESULTS: The 34 patients had phytobezoars (PBZ). Two patients with mental retardation and trichotillomania had trichobezoars (TBZ). More than half of them (55.88%) had previous gastric surgery. Also most of them had small bowel bezoars resulting in obstruction. Surgical and endoscopic morbidity rates were 32.14% and 14.28% respectively.The total morbidity rate of this study was 29.41%. Four patients in surgically treated group died. There was no death in endoscopically treated group. The total and surgical mortality rates were 11.76% and 14.28% respectively. The differences in morbidity and mortality rates between the subgroups were not statistically significant.CONCLUSION: BZ are commonly seen in stomach and small intestine. SBO is the most common complication.When uncomplicated, endoscopic or surgical removal can be applied easily.

Synergistic effect of multiple predisposing risk factors on the development of bezoars

AIM： To describe the clinical characteristics of patients with gastric or intestinal bezoars recently treated in our hospital.

国内报道的儿童胃内毛发结石13例的总结分析及文献复习

目的:对国内文献报道的儿童胃内毛发结石病例13例的临床资料进行总结分析,并对胃内毛发结石及其特殊类型(长发公主综合征)进行文献复习,以提高对该病的认识。方法:对国内文献报道的13例儿童胃内毛发结石的临床资料进行统计分析。结果:13例均为女性,中位数年龄12岁,12例(92%)有食毛癖,常见的临床表现为上腹部疼痛10例(77%),恶心/呕吐8例(62%),体重下降8例(62%)等。11例行胃镜检查,均可见胃内巨大毛发样团块,其中3例发现有胃溃疡。1例行胃镜取石,11例进行外科手术成功取出毛发结石,1例未提供治疗情况。1例随访1年无复发,其余病例未提供随访情况。结论:在有慢性腹痛、呕吐和食毛癖的儿童,胃内毛发结石和长发公主综合征应作为鉴别诊断之一,对高度怀疑的病例,应进一步完善上消化道内镜等检查以明确诊断,使其得到及时、有效的治疗。

Rapunzel syndrome:The unsuspected culprit

Trichobezoar is a rare intriguing disorder in which swallowed hairs accumulates in the stomach. Being indigestible and slippery, it could not be propulsed and becomes entrapped within the stomach. Large amounts can thus accumulate over the years forming a hair ball. Rapunzel syndrome is a variant where hair accumulation reaches the small gut and beyond in some cases. Although the syndrome has been known for many years, only 24 cases have been reported in the literature and the discovery of a new case is always surprising. In this report, we present two cases discovered within a period of three months. One of them was pregnant and had small bowel intussusception and perforation, a very rare combination. We hereby add two more cases to the literature. To our knowledge, this is the first report on two cases of Rapunzel syndrome, the diagnosis of which demands a high index of suspicion.

Rapunzel syndrome:A rare presentation with multiple small intestinal intussusceptions

Bezoars are usually confined to the stomach which is seen in individuals with psychiatric illness like trichotillomania,trichophagia and gastric dysmotility.Long standing bezoars may extend into the small intestine leading to a condition known as Rapunzel syndrome.Diagnosis can be established by endoscopy,ultrasonography and computed tomography scan.Treatment includes improvement of general condition and removal of bezoar by laparoscopic approach or laparotomy.Psychiatric consultation is necessary to treat and prevent relapse.We report a case of Rapunzel syndrome in a 16-yearold girl with trichotillomania.She presented with history of epigastric mass for three months and recent onset of pain abdomen,vomiting and early satiety.Skiagram of abdomen was showing distended stomach and endoscopy revealed trichobezoar.At laparotomy,stomach was distended with trichobezoar and there were multiple small intestinal intussusceptions.Gastrotomy and manual reduction of intussusceptions with the removal of trichobezoar with its tail was done.Patient recovered completely after the procedure.

Rapunzel syndrome is not just a mere surgical problem: A case report and review of current management

Recurrent Rapunzel syndrome(RRS) is a rare clinical presentation with fewer than six cases reported in the Pub Med literature. A report of RRS and literature review is presented. A 25-year-old female was admitted to hospital with a 4-wk history of epigastric pain and swelling. She had a known history of trichophagia with a previous admission for Rapunzel syndrome requiring a laparotomy nine years earlier, aged 16. Psychological treatment had been successfully achieved for nine years with outpatient hypnotherapy sessions only, but she defaulted on her last session due to stressors at home. The abdominal examination demonstrated an epigastric mass. Computer tomography scan revealed a large gastric bezoar and features of aspiration pneumonia. The patient underwent emergency open surgical laparotomy for removal as the bezoar could not be removed endoscopically. The bezoar was cast in a shape that mimicked the contours of the stomach and proximal small bowel, hence the diagnosis of RRS. The patient was seen by a psychiatrist and was commenced on Quetiapine before discharge. She continues to attend follow-up.

巨大毛发性胃石症CT表现1例

患者女,17岁,主因＂上腹部隐痛伴恶心、呕吐10天＂入院。查体：皮肤黏膜轻度苍白;上腹部可触及拳头大小肿块,活动度可。血常规检查提示轻度贫血。腹部CT：轴位平扫示胃腔内团块影约8cm×6cm×17cm,CT值31~81HU,其内密度不均,间杂斑点状低密度影（CT值约-389HU）,增强后无强化（图1A）;冠状位图像示团块影上达胃底,下至胃窦部,周边可见液体围绕（图1B）。

超声诊断巨大毛发性胃结石一例及文献复习

目的:探讨毛发性胃结石的影像表现、临床特点及治疗。方法:回顾性分析1例毛发性胃结石患者的临床资料,结合文献报道,对其影像、临床表现和治疗方法进行探讨。结果:患者为一女性患儿,上腹痛不适半年余,既往有拔毛癖,超声诊断胃巨大毛发性结石,内镜证实后开腹手术,取石成功,随访痊愈。结论:毛发性胃结石与其它胃结石相比,影像表现、临床特点无明显差异,超声检查可提供可靠的诊断提示,治疗需取出结石以消除症状,并注意心理干预,防止复发。