El largo camino de la tricotilomania al síndrome de Rapunzel / The Long Road from Trichotillomania to Rapunzel Syndrome

Introducción: La tricotilomania, la tricofagia y el tricobezoar son afecciones entrelazadas e interconectadas. Estas deben tenerse en cuenta especialmente en féminas jóvenes que a menudo tienen una enfermedad psiquiátrica o trastorno social subyacente y es posible que la historia sea difícil de obtener. Objetivo: Presentar un caso portador de tricobezoar gástrico, por su baja incidencia en nuestro medio y a nivel mundial. Caso clínico: Paciente femenina de 12 años de edad, con antecedentes de retraso psicomotor, sin seguimiento o tratamiento previo. Acudió a consulta traída por su madre que aduce aumento de volumen en hemiabdomen superior de 5 años de evolución con pérdida de peso insidiosa. Los estudios radiológicos revelaron un tricobezoar gástrico que se corrobora, asociado a un síndrome de Rapunzel, en la laparotomía exploratoria. La paciente evolucionó satisfactoriamente y es seguida por grupo multidisciplinario. Conclusiones: Los bezoares gástricos son entidades poco frecuentes. Para el diagnóstico es necesario un alto índice de sospecha de conjunto con estudios radiográficos y/o endoscópicos. El tratamiento estará determinado por el tipo de bezoar, tamaño y consistencia. La opción quirúrgica es la más usada, con el consecuente seguimiento interdisciplinario para evitar recurrencias(AU)

Introduction: Trichotillomania, trichophagia and trichobezoar are intertwined and interconnected conditions. These should be considered, especially in young women who often have an underlying psychiatric illness or social disorder and possibly a history difficult to get. Objective: To report a case of gastric trichobezoar due to its low incidence in our environment and worldwide. Clinical case report: We report the case of a 12-year-old female patient with a history of psychomotor retardation, with no prior follow-up or treatment, who came to consult with her mother, complaining of increased volume in the upper abdomen, of 5 years of evolution with malignant weight loss. Radiological studies reveal a gastric trichobezoar that is corroborated, associated with Rapunzel syndrome, in the exploratory laparotomy. The patient evolved satisfactorily and a multidisciplinary group assisted her. Conclusions: Gastric bezoars are rare entities. Diagnosis requires high level of suspicion together with radiographic and/or endoscopic studies. The treatment will be determined by the type of bezoar, size and consistency. The surgical option is the most used, requiring interdisciplinary follow-up to avoid recurrences(AU)

Síndrome de Rapunzel como complicación en una paciente lúpica / Rapunzel syndrome as a complication in a lupus patient

El lupus eritematoso sistémico es una enfermedad que causa un gran número de complicaciones de origen psicológico; estas pueden llevar a patrones inadecuados de conducta que pueden poner en riesgo la vida de los pacientes como el síndrome de Rapunzel. Se describen los elementos clínicos y diagnósticos de este síndrome mediante el caso de una paciente femenina de 25 años de edad, con diagnóstico de lupus eritematoso sistémico. Acude a consulta con manifestaciones clínicas e imagenológicas que permiten llegar al diagnóstico de síndrome de Rapunzel como complicación psicológica en el curso del lupus eritematoso sistémico. Se procede a realizar la intervención quirúrgica donde se halló una masa tumoral constituida por cabello humano. En la actualidad, la paciente se mantiene en seguimiento por las especialidades de reumatología, psiquiatría y psicología, y su recuperación y evolución han sido satisfactorias. El lupus eritematoso condiciona conductas que pueden ser perjudiciales para la salud de los pacientes. Es importante la identificación precoz de conductas como la tricotilomanía y el seguimiento psicológico especializado en pacientes con esta enfermedad(AU)

Systemic lupus erythematosus is a systemic disease that generates a large number of complications of psychological origin; these can lead to inappropriate behavior patterns that can be life-threatening for patients. To describe the clinical and diagnostic elements of Rapunzael syndrome. Clinical case: a 25-year-old female patient with a diagnosis of systemic lupus erythematosus who consulted with clinical and imaging manifestations that led to the diagnosis of Rapunzel syndrome as a psychological complication in the course of systemic lupus erythematosus. Lupus erythematosus conditions a series of behaviors that can be detrimental to the health of patients; early identification of behaviors such as trichotillomania and specialized monitoring in psychology in patients with this disease is important. The clinical evolution of the patient has been very favorable and her general condition has recovered(AU)

Gastric trichobezoar and Rapunzel syndrome: a case report

Giant gastric trichobezoars are unusual form of foreign body found in stomach of mostly young adolescent females which may lead to morbidity and high mortality 30%, if goes unnoticed. These females have history of trichophagia or trichotillomania. This report is of a 12- year old young adolescent female presented with epigastric pain and mass. An exploratory laparotomy with anterior gastrotomy was performed and a giant trichobezoar with a very large tail of 2.5 ft was removed, weighing 2.52 kg. She recovered well and was discharged on 7th post-operative day. Patient was advised for psychiatric follow up.

Tricobezoar: presentación de caso / Trichobezoar: presentation of case

Los tricobezoares pertenecen a la clasificación de los bezoares, tumores abdominales formados por el acumulo de diversas sustancias que pueden ocasionar la oclusión intestinal, se presenta un paciente, femenina, que acuda al médico por presentar dolor abdominal y vómitos, en el examen físico abdominal se palpa una masa de aproximadamente 5 cm en el epigastrio que aparece y desaparece con los movimientos intestinales, se plantea inicialmente la posibilidad de padecer de una neoplasia abdominal, se realiza una endoscopia en donde informe que, en el fondo gástrico, cuerpo y antro está ocupado por cabello y restos alimenticios mal digeridos, la cual es removida mediante una laparotomía sobre el área que ocupaba la tumoración en el intestino delgado extrayendo un tricobezoar de 35 cm de longitud por 10 de ancho(AU)

The trichobezoars belong to the classification of bezoars, abdominal tumors formed by the accumulation of various substances that can cause intestinal occlusion, a patient, female, who comes to the doctor due to abdominal pain and vomiting, in the abdominal physical examination is presented palpa a mass of approximately 5 cm in the epigastrium that appears and disappears with bowel movements, initially poses the possibility of suffering from an abdominal neoplasm, an endoscopy is performed where it reports that, in the gastric fundus, body and antrum is occupied by hair and badly digested food remains, which is removed by a laparotomy on the area occupied by the tumor in the small intestine, extracting a trichobezoar measuring 35 cm long by 10 cm wide(AU)

Síndrome de Rapunzel en una adolescente: causa de suboclusión intestinal / Rapunzel syndrome in teenager: Intestinal subocclusion cause

Resumen Objetivo: Presentar un caso de síndrome de Rapunzel. Esta es una enfermedad poco frecuente que consiste en una variante de tricobezoar gástrico que se extiende hasta la segunda porción del duodeno. Caso clínico: Paciente femenina adolescente con antecedentes de atresia tricuspídea tratada quirúrgicamente. Presentó dolor abdominal de 3 días de evolución en el hipocondrio izquierdo irradiado al hipocondrio derecho, con distensión abdominal, náuseas y vómitos. Al examen físico presentó un perímetro abdominal de 58 cm y ruidos hidroaéreos disminuidos. La laparotomía exploratoria con gastrostomía anterior mostró una masa de cabellos entrelazados de aproximadamente 40 cm de longitud, compatible con tricobezoar, que se extendió desde el fondo gástrico hasta la segunda porción, llamado síndrome de Rapunzel, provocando suboclusión intestinal. Conclusión: El diagnóstico temprano permite evitar complicaciones, que pueden ser graves. Se recomienda un manejo multidisciplinario con el servicio de psiquiatría para controlar la enfermedad de base.

Abstract Aim: Present a case of Rapunzel syndrome, this is a rare disease that is a variant of gastric tricobezoar which extends to the second portion of duodenum. Case report: Female patient with tricuspid atresia treated surgically. Abdominal pain three days of evolution on the left upper quadrant radiating to the right upper quadrant with abdominal distension, nausea and vomiting. Abdominal circumference was 58 cm, decreased bowel sounds. The exploratory laparotomy presenced of a mass formed by interlocking hair, approximately 40 cm long with a compatible tricobezoar that spread from the gastric fundus to the duodenum called Rapunzel síndrome and caused partial bowel obstruction. Conclusion: Early diagnosis can prevent complications, which can be severe, a multidisciplinary management is recommended in psychiatry service to control the underlying disease.

Stomach trichobezoar (rapunzel syndrome) with iatrogenic intussusception

We present a rare case of stomach trichobezoar complicated with iatrogenic intussusception noted intra-operatively after failed attempt of endoscopic removal in a 13-year-old girl. At presentation, she had gastric outlet obstruction with anaemia. Endoscopy established the diagnosis of trichobezoar. Surgical removal was warranted after failed endoscopic removal. Her postoperative course was uneventful. Detailed history and careful examination disclosed trichotillomania and associated trichophagia. Psychiatric referral was sought with the intention to prevent future recurrence.

A rare case of paediatric trichotillomania complicating into Rapunzel syndrome: a case report

Background: Trichotillomania is a psychological condition that involves strong urge to pull one’s hair. Trichophagia is disorder of eating of hair. Bezoar is collection of undigested material such as hair, drugs and plastic or combinations. Rapunzel syndrome is a rare type of trichobezoar, which has mass of hair lodged in stomach extending up to ileum. In majority, diagnosis is made very late, at a stage where surgery is the only option. Case description: A 9 year old girl was brought with complaints of loss of hair on scalp since 8 months, decreased appetite, and constipation, weight loss since 5 months and vomiting since 2 weeks. Patient had paediatric consultations without much benefit; patient was referred to dermatologist and paediatric surgeon. Ultrasound showed mass in abdomen. Patient was operated to find a mass extending from stomach to terminal ileum. Patient was referred to a Psychiatrist and diagnosis of Trichotillomania was made. Discussion: Trichobezoar is common in young females, often with an underlying psychiatric disorder, they present late due to the low index of suspicion. As this condition is a rarity in paediatric age group and very little progress to Rapunzel syndrome, this paper discusses about the systemic team management of the above individual. Conclusion: High index of suspicion is needed to diagnose this condition in paediatric age group.

A Case of Rapunzel Syndrome / 대한소아소화기영양학회지

Rapunzel syndrome refers to a very rare condition in which swallowed hair forms a gastric trichobezoar that has a long tail extending into the small bowel. We describe a case of Rapunzel syndrome in an 8-year-old girl who presented with abdominal mass, epigastric pain and vomiting. Abdominal computed tomography scan showed a markedly dilated stomach filled with coarse heterogeneous materials. Upper gastrointestinal endoscopy revealed a huge hairy ball with a tail extending through the pylorus. We performed a surgical laparotomy and successfully removed a huge trichobezoar with a long tail extending into the middle portion of jejunum. Psychiatric consultation with review showed her past history of trichotillomania and trichophagia 4 years ago. But her parents denied further psychiatric therapy and she was lost to the follow-up. Rapunzel syndrome should be included in the differential diagnosis in children with chronic abdominal pain and trichophagia.

Rapunzel Syndrome : A Rare Cause of Vomiting and Pain Abdomen.

Bezoar is an agglomeration of food or foreign material in intestinal tract. Contiguous extension of trichobezoar into the small bowel can lead to the Rapunzel syndrome. We present rare case of Rapunzel syndrome in 16 year old female who presented with recurrent vomiting.

Síndrome de Rapunzel: reporte de caso y revisión de la literatura / Rapunzel syndrome: a case report and literature review

Los tricobezoares son una condición poco común que usualmente ocurre en mujeres jóvenes con una historia de tricotilomanía y tricofagia. En la actualidad, la mayoría de los casos se presentan en pacientes con antecedentes de cirugía gástrica, o con alteraciones en la función pilórica; clínicamente pueden cursar asintomáticos durante meses o años o presentarse como una entidad aguda acompañada por sus complicaciones. En el presente artículo se presenta el caso clínico de una paciente embarazada a quien se le realizó diagnóstico de tricobezoar gastroduodenal - síndrome de Rapunzel (una variedad compleja de este bezoar que involucra estómago, duodeno e intestino); se presenta una revisión de la literatura al respecto.

The presence of trichobezoars is a rare condition which usually occurs in young women who have histories of trichotillomania and trichophagia. Nowadays, the majority of cases occur in patients with a history of gastric surgery, or pyloric function alteration. They may be clinically asymptomatic for months or years or may present acute symptoms accompanied by severe complications.This article presents the case of a pregnant patient who was diagnosed with a case of Rapunzel syndrome a is presented. This complex variety of gastroduodenal trichobezoar involves the stomach, duodenum and intestine. The article also reviews the literature about the Rapunzel syndrome.

Tricobezoar gástrico y síndrome de Rapunzel en una adolescente / GastricTrichobezoar and Rapunzel syndrome in an adolescent

Se describe el caso clínico de una adolescente de 17 años de edad, con malas condiciones sociales, ingresada en el Hospital San Juan de Dios, municipio de Challapata (Bolivia), por presentar epigastralgia, náuseas y vómitos. Se realizó endoscopia digestiva superior y se confirmó un cuadro de oclusión intestinal alta por tricobezoar gástrico en forma de síndrome de Rapunzel, por lo cual fue operada de urgencia. La evolución posoperatoria resultó favorable y egresó a los 7 días, con recomendaciones de asistir a consultas externas de cirugía general y psicología

The case report of a 17 year-old adolescent , with poor social conditions, admitted at San Juan de Dios Hospital, Challapata municipality (Bolivia), for presenting epigastralgia, nauseas and vomits is described . An upper digestive endoscopy was carried out and a case of upper intestinal occlusion due to gastric tricobezoar simulating a Rapunzel syndrome was confirmed, reason why she had an emergent surgery. The postoperative clinical course was favorable and she was discharged after 7 days, with recommendations of attending the out patient department of general surgery and psychology

Tricotilomanía, tricobezoar de repetición y síndrome de Rapunzel: informe de un caso y revisión de la literatura / Trichotillomania, recurrent trichobezoar and Rapunzel syndrome: case report and literature review

Introducción: Un bezoar es un conglomerado de material extraño en el tracto intestinal. El tricobezoar (acumulación de cabello en la cámara gástrica) y el síndrome de Rapunzel (acumulación en el intestino delgado) suelen aparecer en niños y mujeres adolescentes con antecedente de tricotilomanía y tricofagia. Caso clínico: Mujer de 22 años de edad con dolor abdominal intermitente, plenitud gástrica, náuseas, vómito ocasional y pérdida ponderal de 10 meses de evolución. Antecedentes de tricotilomanía, tricofagia y gastrotomía a los 16 años. Los exámenes de laboratorio revelaron anemia microcítica hipocrómica y el ultrasonido mostró una sombra sónica posterior en la cámara gástrica. Por gastrotomía se extrajo un conglomerado de cabello que ocupaba el estómago y parte del intestino delgado. Conclusiones: La tricotilomanía y tricofagia son más comunes en las mujeres menores de 30 años. La sensación que experimentaba la paciente al deglutir los cabellos provocaba la ingesta. La recopilación de datos puede proporcionar información acerca de los determinantes que influyen en la aparición de la enfermedad.

BACKGROUND: 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 (TTM) and trichophagia history. CLINICAL CASE: We present the case of a 22-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 TTM, trichophagia and previous gastrotomy at 16 years of age. 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 and part of the small intestine. CONCLUSIONS: TTM is characterized by recurrent and impulsive pulling of one's hair for pleasure, gratification, or relief of tension. Children and women <30 years of age are the groups who most frequently suffer from this type of disorder. Hair intake sensation was a cause for presentation of the disease. Data recollection in our environment may provide information for the determination of new information regarding the presence of this condition.

Síndrome de Rapunzel (tricobezoar gástrico con extensión a duodeno y yeyuno): a propósito de un caso / Rapunzel syndrome (gastric trichobezoar extending into duodenum and jejunum): report of a case

El síndrome de Rapunzel, corresponde a un raro fenómeno con pocos casos comunicados y descritos en la literatura mundial. Así pues, compartimos un nuevo caso. Se trata de paciente femenino de 6 años de edad, que consulta por presentar desde hace 2 meses crisis de epigastralgia, vómitos a repetición y pérdida de peso. Su sintomatología ha empeorado en la última semana y refiere sensación de masa en epigastrio. Como antecedente importante tricofagia de dos años de evolución. Al examen se palpa masa epigástrica alargada. Al ecosonograma abdominal se aprecia en epigastrio, en la zona que corresponde a la cámara gástrica, una línea hiperecogénica, curvilínea, discretamente heterogénea, que produce sombra acústica completa, sugestivo de masa ecogénica de más de 5 cm de longitud . La radiología de estómago muestra una imagen de defecto que se extiende desde el cuerpo hasta la región antropilórica, de 6 x 4 cms. La Videogastroscopia muestra una concreción de pelos (tricobezoar), que se extiende a través del píloro. El 26-02-2009 es intervenida quirúrgicamente, se realiza gastrostomía con extracción de tricobezoar que se extiende a través del duodeno hasta el yeyuno. En ocasiones el tricobezoar se extiende más allá del estómago, alcanzando duodeno, yeyuno, ileon, e incluso colon, dándosele entonces, el nombre de Síndrome de Rapunzel...

The Rapunzel syndrome is a rare condition with few cases reported and described in the literature. Thus, WE SHARE a new case. Is a 6 years old female patient who went to consult because she had had from 2 months ago epigastralgia`s crisis, vomits and regurgitation, and lost of weight. Her symptomatology has gotten worst in the last week and refers a sensation of a mass in the epigastrium. As an important background she had had trichophagia of two years evolution. An elongated epigastric mass is felt on examination. The abdominal echosonogram shows a hyperechoic curvilinear line, discretely heterogeneous, in the epigastrium, specifically, in the gastric zone, which produces a complete acoustic shadow allusive of echogenic mass of more than 5 cm. of length. The stomach radiography shows a defect image of 6 x 4 cm. that extends from the body to the antro-pyloric region. The video-gastroscopy reveals a hair concretion (trichophagia) that extends through the pylorus. On February 26, 2009 the patient underwent surgical intervention, a gastrostomy with extraction of the trichobezoar that expands through the duodenum to the jejunum. In occasions the trichobezoar extends beyond the stomach reaching to the duodenum, jejunum, ileum and even colon, that's when it's called Rapunzel Syndrome...

Trichobezoar: Two Cases of Unusual Presentation

Two cases of trichobezoar with unusual presentation in female children are described. The first case is a 7-year-old female with a 3-day history of abdominal pain, obstipation, and emesis. She developed intestinal obstruction and showed double bezoars in the stomach and intestine respectively. She had been in a habit of biting or sucking hairs before sleeping from infancy until 5 years of age. The other patient is a 6-year-old girl referred for an epigastric mass, emotional disturbance and trichotillomania. In spite of the psychological treatment, 4 laparotomies were necessary due to repeated recurrences.

Case of the Rapunzel Syndrome in a Child

Rapunzel syndrome is a rare form of gastric trichobezoar extending through the small bowel and develops after swallowing hairs or carpet which are trapped in the gastric mucosa and become enmeshed. In adult, it occurs most frequently after a gastric resection, but in children, it is frequently associated with pica, mental retardation, and coexistent psychiatric pathologic disorders. This syndrome is usually found in girls with varying gastrointestinal symptoms due to gastric outlet obstruction or secondary ulcerations. Although most small trichobezoars are removed easily by using a gastrofiberscope, surgical removal is recommended for large or complicated trichobezoar. In this syndrome, psychiatric treatment should follow to diminish the frequency of recurrence. We report the case report of a 6-year-old girl who frequently swallowed of her hairs for 3 years, resulting in frequent vomiting and an epigastric palpable mass in which a gastric trichobezoar extended to the duodenum and proximal jejunum.