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)

Bezoar gástrico gigante. Presentación de un caso / Giant gastric bezoar. Presentation of case / Bezoar gástrico gigante. Apresentação de um caso

RESUMEN Se realizó un reporte de un caso de paciente femenina de 48 años de edad, con antecedentes patológicos personales de hipertensión arterial, cardiopatía isquémica, arritmias cardíacas y neurosis depresiva e ingestión diaria de cuerpos extraños desde hace algunos años, la cual tenía el hábito de masticar fragmentos de espuma de poliestireno (poliespuma), los que diluía en gasolina para poderlos moldear, ablandar e ingerirlos posteriormente. La paciente acudió a la consulta de Gastroenterología por presentar epigastralgia, acidez, sensación de repletes gástrica posprandial, aun cuando solo podía digerir escasas cantidades de alimento. Se realizó endoscopia, donde se apreció a la entrada de la luz gástrica un bezoar gigante de consistencia dura, superficie lisa, no movible, que midió aproximadamente 6-7 cm de diámetro, que ocupó prácticamente el 50 % de la luz gástrica, correspondiente al fundus y cuerpo gástrico, con extensión hacia el antro. Los intentos de extraerlo por vía endoscópica fueron fallidos, por lo que se intervino quirúrgicamente y se extrajo el mismo. La paciente tuvo una evolución posoperatoria favorable y egresó a los siete días, con seguimiento por consulta externa y tratamiento médico ambulatorio.

ABSTRACT A 48-year-old female presented to gastroenterologist consultation with epigastralgia, heartburn, and sensation of postprandial gastric fullness even when she only could intake meal in small proportion. She had a history of hypertension, ischemic heart disease, and cardiac arrhythmias, depressive neurosis associated to the ingestion, daily and since several years, of foreign bodies. She was used to chewing fragments of polyfoam, which she diluted them in gasoline in order to mold them, soften them and ingests them afterwards. An endoscopy procedure was used, which revealed, at the entrance of the gastric lumen, a giant bezoar of hard mass, smooth surface, non-movable, with approximately 6-7 cm size and occupying almost 50% of the gastric lumen region corresponding to the gastric body and fundus, and extending to the antrum. Attemps for removal the mass, endoscopically, were unsuccessful, so surgery was performed and it was removed successfully. The patient had a favorable postoperative evolution and was discharged 7 days after surgery, with outpatient follow-up and ambulatory medical treatment.

RESUMO Relatou-se o caso de uma paciente do sexo feminino, 48 anos, com história patológica pessoal de hipertensão arterial, cardiopatia isquêmica, arritmias cardíacas e neurose depressiva e ingestão diária de corpos estranhos há alguns anos, que tinha hábito de mastigar fragmentos de espuma de poliestireno (polyfoam), que ele diluiu em gasolina para poder moldar, amolecer e ingerir depois. A paciente compareceu à consulta de Gastroenterologia por apresentar epigastralgia, azia, sensação de plenitude gástrica pós-prandial, embora só conseguisse digerir pequenas quantidades de alimentos. Foi realizada endoscopia, onde um bezoar gigante de consistência dura, superfície lisa, imóvel, medindo aproximadamente 6-7 cm de diâmetro, ocupando praticamente 50% da luz gástrica, correspondente à luz gástrica, foi observado na entrada do lúmen gástrico, fundo e corpo gástrico, com extensão em direção ao antro. As tentativas de removê-lo endoscopicamente não tiveram sucesso, então ele foi submetido a uma cirurgia e foi removido. O paciente teve evolução pós-operatória favorável, com alta hospitalar sete dias após, com acompanhamento ambulatorial e acompanhamento médico ambulatorial.

Tricobezoar: reporte de caso / Case report: Trichobezoar

Reportamos el caso de una adolescente femenina que ingresa al Hospital Mario Catarino Rivas en San Pe- dro Sula con antecedente de tricofagia desde hace 5 años. Ingresa con historia de dolor abdominal epigás- trico de 3 meses de evolución con náuseas y vómitos de alimentos ocasionales junto a pérdida de aproxima- damente 6 kilogramos de peso en los últimos 3 meses. Paciente fue ingresada y se completaron estudios diagnosticándose tricobezoar gástrico con poste- rior intervención quirúrgica: laparotomía media supraumbilical accediendo al estómago sobre el cual se le realizó una gastrostomía antral de 6 cm de longitud por donde se extrae el bezoar en su to- talidad. Se cierra posteriormente la gastrotomía.

Bezoar gástrico, una aproximación al manejo / Gastric bezoar, an approach to medical management

The presence of bezoars in daily clinical practice is a event that poses a challenge both diagnostic, due to the associated factors in its development, as well as therapeutic. The management of this entity is associated with medical, endoscopic and surgical procedures and it is necessary to know its usefulness in different clinical scenarios. The role of carbonated beverages is increasingly accepted given its low cost, wide availability and high efficiency. For the aforementioned, it seems important to report a series of cases and the management performed.

La presencia de bezoares en la práctica clínica diaria es un evento que establece un desafío diagnóstico, por los factores asociados en su desarrollo, como también terapéutico. El manejo de esta patología se asocia a procedimientos médicos, endoscópicos y quirúrgicos siendo necesario conocer su utilidad en distintos escenarios clínicos. El rol de las bebidas carbonatadas es cada vez más aceptado dado su bajo costo, amplia disponibilidad y alta eficacia. Por lo antes señalado, nos parece importante reportar una serie de casos y el manejo realizado.

Tricobezoar de estómago / Gastric Trichobezoar Rapunzel Syndrome

Trichobezoars are an unusual pathology that appears generally in young adolescents associated with psychiatric disorders. The clinical presentation is very varied. The diagnosis is suspected by the clinical records of teen agers with trichophagia and trichotillomania and the digestive disorders are confirmed by the results of the endoscopy, the same as with images toward the therapeutic management. Undowbtly the treatment is surgical, and continuation with the psychiatric treatment is essential to avoid a recidival of the disease. Bezoar is a concretion formed in the alimentary tract, and according to the substances forming the ball, we find trichobezoar (foodball). The Rapunzel syndrome is an unusual complication of individual bezoar. When the trichobezoar located in the stomach extends through the pylorus into the small intestine and the right colon, is known as Rapunzel syndrome, that is an extremely rare gastric condition in humans. It is a rare form of trichobezoar, occurring in psychiatric patients with the trichobezoar (hairball) located in the stomach. The syndrome is named after the long haired girl Rapunzel in the fairy tale of the brothers Grimm. Most bezoars in teen agers are trichobezoars from swallowed hair. A 28-year-old patient is presented, with abdominal pain and vomiting, on the general physical examination the patient revealed a severe weight loss. Later on, through a gastrostomy, appeared the trichobezoar, being removed with good postsurgical resullts

Colonic phytobezoar / Fitobezoar cólico

ABSTRACT Bezoars, although rare, represent a small part of the etiologies of intestinal obstructions. They are indigestible masses formed in human beings consisting of hair, seeds, plant fibers, fruits, and even medications. The present report concerns a male patient with a complaint of interrupted flatus passage and feces elimination and pain in the left iliac fossa, initially suspected as a neoplasia of the sigmoid colon. However, analysis of the surgical specimen revealed that the condition was characterized by intestinal obstruction due to an encapsulated phytobezoar. This fact demonstrates the importance of a differential diagnosis, with emphasis on the relevance of considering the presence of bezoars despite their rare occurrence.

RESUMO Os bezoares, embora raros, representam uma pequena parte das etiologias das obstruções intestinais. São massas indigestíveis formadas em seres humanos que consistem em cabelo, sementes, fibras vegetais, frutas e até mesmo medicamentos. O presente relato retrata um paciente do sexo masculino com uma queixa de parada de eliminação de flatos e fezes somado à dor na fossa ilíaca esquerda, que inicialmente suspeitou-se como neoplasia do cólon sigmoide. No entanto, a análise das peças cirúrgicas revelaram que a obstrução intestinal ocorreu devido à presença de um fitobezoar encapsulado. Este fato demonstra a importância do diagnóstico diferencial, com ênfase em considerar a presença de bezoares apesar de sua rara ocorrência.

Síndrome de Rapunzel con doble tricobezoar simultáneo en una adolescente: Reporte de caso / Rapunzel syndrome with double simultaneous trichobezoar in a teenager: Clinical Case Report

Resumen: Introducción: Los tricobezoares son acúmulos intraluminales de cabello ingerido. El síndrome de Rapunzel hace referencia a la presencia de los tricobezoares gástricos que se extienden al intestino delgado, sumados a la tricotilomanía y tricofagia, los cuales ocurren preferentemente en pacientes psiquiátricos en edad pediátrica. Objetivo: Analizar la aparición y manejo de este síndrome, propor cionando de igual manera datos acerca del entorno familiar y psicoemocional para que, por medio del análisis de los mismos, en un futuro se pueda identificar el riesgo en pacientes con circunstancias similares. Caso clínico: Paciente femenina de 14 años con antecedentes de tricotilomanía y tricofagia de dos años de evolución, que consultó por cuadro de dolor epigástrico asociado a sensación de plenitud posprandial, náuseas y pérdida de peso. Al examen destacaban áreas alopécicas en el cuero cabelludo y a la palpación abdominal se identificó un plastrón cuyo contorno parecía corresponder a los límites gástricos. En los estudios de imágenes se encontró una ocupación gástrica por bezoar. Con la laparotomía más gastrostomía se identificaron dos tricobezoares simultáneos en estómago y duodeno, que fueron resueltos quirúrgicamente y la paciente fue manejada con abordaje psicoemocional. Conclusión: El síndrome de Rapunzel, lejos de ser meramente una entidad quirúrgica, requiere un apoyo psicoemocional para prevenir su recurrencia y limitar su severidad.

Resumen: Introduction: Trichobezoars are an intraluminal accumulation of ingested hair. The Rapunzel syndrome refers to the presence of gastric trichobezoars which extend to the small intestine together with trichotillomania and trichophagia, that occur predominantly in psychiatric patients of pediatric age. Objective: To analyze the clinical course and resolution of this syndrome in a case report. Likewise, we provide information about the family environment and psycho-emotional context of the patients and help the reader identify similar circumstances in their clinical practice. Case report: Female 14-year-old patient with history of trichotillomania and trichophagia of two years of evolution, who consulted for epigastric pain associated with weight loss, nausea, and postprandial fullness. During the physical examination, the patient was found to have bald patches in the scalp along with a palpable mass that seemed to be confined to the gastric limits. Imaging studies revealed gastric occupation due to a bezoar formation. The patient was treated surgically with laparotomy and gastrostomy, and two simultaneous trichobezoars were removed from the patient´s stomach and duodenum, the patient also underwent psycho-emotional professional counseling. Conclusion: Rapunzel´s syndrome, far for being a merely surgical entity, also requires psychoemotional assessment to prevent it recurrence and limit its severity.

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.

Compactação ruminal e obstrução intestinal em bovinos, associadas ao consumo de Agave sisalana Perrine (Agavaceae) / Ruminal indigestion and intestinal obstruction in cattle associated with consumption of Agave sisalana Perrine

A compactação dos pré-estômagos é um transtorno digestivo resultante da ingestão de forragem de baixa qualidade, rico em lignina e com baixos níveis de energia e proteína digerível, associada ou não a restrição hídrica. O acúmulo de vegetais ricos em fibras indigeríveis pode levar também a formação de fitobezoares, causando transtornos digestivos e obstruções intestinais. Objetivou-se com este trabalho descrever os aspectos epidemiológicos e as alterações clínico-patológicas de um surto de alterações digestórias em bovinos alimentados com Agave sisalana. O rebanho acometido era formado por 22 animais adultos, criados de forma semiextensiva, que, devido a escassez de forragem, receberam no cocho, quase que exclusivamente, durante dois meses, o caule do A. sisalana cortado manualmente. Seis vacas apresentaram diminuição do apetite, distensão abdominal, redução dos períodos de ruminação e da produção de fezes. Um animal foi encaminhado ao Hospital Veterinário da Universidade Federal de Campina Grande. O diagnóstico presuntivo de compactação ruminal e obstrução intestinal foi dado pela epidemiologia, sinais clínicos e análise de fluido ruminal. Na necropsia observou-se rúmen, retículo e omaso repletos, com conteúdo fibroso e ressecado constituído por fibras de A. sisalana. No abomaso observou-se a presença de conteúdo pastoso e esverdeado a acastanhado. Em todos os pré-estômagos e no abomaso havia fitobezoares, que mediam entre 4 e 12 cm de diâmetro. No duodeno um fitobezoar obstruía parcialmente a luz do órgão, com a porção anterior repleta de conteúdo e a posterior vazia. Conclui-se que a alimentação com caules de A. sisalana por longos períodos causa compactação de pre-estômagos e formação de fitobezoares.(AU)

Indigestion due to compaction of the ruminal content is a digestive disorder resulting from low-quality forage intake, rich in lignin and with low levels of energy and digestible protein, with or without water restriction. The accumulation of plant residues rich in indigestible fibers can also lead to formation of phytobezoars, causing digestive disorders and intestinal obstructions. The objective of this paper was to describe the epidemiology and the clinical and pathological changes of an outbreak of indigestion and other digestive disorders in cattle fed Agave sisalana. The affected herd consisted of 22 adult cattle reared in a semi-extensive system, which ingested almost exclusively stalks of A. sisalana manually cut for two months. Six cows showed decreased appetite and rumination, abdominal distension, and reduced production of dried feces. One animal was referred to the Veterinary Hospital. The presumptive diagnosis of indigestion was made by the epidemiologic data, clinical signs, and laboratory evaluation. At necropsy, the rumen, reticulum and omasum were filled with fibrous and dried A. sisalana content. A viscous, greenish brownish content was present in the abomasum. Numerous phytobezoars were found in the pre-stomachs and abomasum measuring 4-12cm in diameter. One phytobezoar was partially obstructing the duodenum, with the cranial part of the organ filled with intestinal content, and the caudal portion was empty. It is concluded that the administration of A. sisalana stalks for long periods may cause indigestion due to ruminal compaction and formation of phytobezoars.(AU)

Oclusión intestinal mecánica por fitobezoar / Mechanical intestinal occlusion by phytobezoar

Los bezoares son recolecciones de material orgánico no digerible, que luego de ser ingerido, se acumulan con el tiempo en el estómago o intestino delgado. La presentación más común del bezoar es en la forma de fitobezoar, el cual es causado por la acumulación de partículas sin digerir de origen vegetal. Los fitobezoares son responsables de sólo 0,4-4 por ciento de todas las obstrucciones intestinales. Se presenta un paciente masculino de 51 años hospitalizado e intervenido quirúrgicamente por presentar una oclusión intestinal que en el acto operatorio se constató que la causa fue por fitobezoar. La presentación como oclusión intestinal es muy rara, dado que sigue un curso insidioso y progresivo. El diagnóstico de oclusión intestinal por bezoar puede resultar muy difícil, ya que es una entidad muy poco frecuente y la historia de la ingesta de estos materiales es rara vez expresada espontáneamente. El diagnóstico de oclusión intestinal secundaria a fitobezoar requiere de tratamiento quirúrgico precoz, ya que su retraso conlleva a una elevada morbimortalidad. El fitobezoar es una causa rara de obstrucción de intestino delgado. Su sospecha clínica es frecuentemente pasada por alto. Es importante conocer la conducta a seguir en estos casos para garantizar un correcto tratamiento(AU)

Bezoars are collections of indigestible organic material, which accumulate in the stomach or small intestine after being ingested. The most common presentation of bezoar is in the form of phytobezoar, which is caused by the accumulation of undigested particles of vegetable origin. Phytobezoars are responsible for 0.4-4 percent of all intestinal obstructions. A 51-year-old male patient was hospitalized and operated, after presentation with an intestinal occlusion. During the surgical procedure, the cause was found to be fitobezoar. This type of intestinal obstruction is much rare; it follows an insidious and progressive course. Its diagnosis can be much difficult; history of disagreement regarding these materials is rarely expressed by patients spontaneously. The diagnosis of intestinal secondary occlusion by phytobezoar requires early surgical treatment because the delay has led to high morbidity and mortality. The phytobezoar is a rare cause of small bowel obstruction. Ii is often ruled out as clinical suspicion. It is important to know how to perform in these cases, in order to ensure proper treatment(AU)

Clinical Outcomes Associated with Treatment Modalities for Gastrointestinal Bezoars

BACKGROUND/AIMS: With technical and instrumental advances, the endoscopic removal of bezoars is now more common than conventional surgical removal. We investigated the clinical outcomes in a patient cohort with gastrointestinal bezoars removed using different treatment modalities. METHODS: Between June 1989 and March 2012, 93 patients with gastrointestinal bezoars underwent endoscopic or surgical procedures at the Asan Medical Center. These patients were divided into endoscopic (n=39) and surgical (n=54) treatment groups in accordance with the initial treatment modality. The clinical feature and outcomes of these two groups were analyzed retrospectively. RESULTS: The median follow-up period was 13 months (interquartile range [IQR], 0 to 77 months) in 93 patients with a median age of 60 years (IQR, 50 to 73 years). Among the initial symptoms, abdominal pain was the most common chief complaint (72.1%). The bezoars were commonly located in the stomach (82.1%) in the endoscopic treatment group and in the small bowel (66.7%) in the surgical treatment group. The success rates of endoscopic and surgical treatment were 89.7% and 98.1%, and the complication rates were 12.8% and 33.3%, respectively. CONCLUSIONS: Endoscopic removal of a gastrointestinal bezoar is an effective treatment modality; however, surgical removal is needed in some cases.

Síndrome de Rapunzel: revisão de literatura / Rapunzel syndrome: a literature review

Tricobezoar gastroduodenal é definido como o acúmulo de cabelos e pelos no trato gastrointestinal, tendo como origem a ingestão dessas substâncias. As autoras relatam o caso de um volumoso tricobezoar associado à síndrome de Rapunzel, em jovem do sexo feminino com história de tricotilofagia e emagrecimento. Foram utilizados, como base de dados, a revisão de prontuário, a avaliação dos exames realizados e o acompanhamento durante o ato operatório. Apesar de ser um caso incomum, é necessário aventar sua hipótese diagnóstica diante de uma clínica exuberante como a da referida paciente. Não somente o bezoar deve ser adequadamente tratado, mas também a causa subjacente que levou a paciente à ingestão de cabelos.

Gastroduodenal trichobezoar is the accumulation of hair inside the gastroduodenal tract, originated by the ingestion of such object. On the presented study is reported the case of a voluminous trichobezoar associated with Rapunzel's syndrome on a young female with history of trichophagia and weight loss. With this purpose, chart review, assessment of the tests, and monitoring during the surgery were used. Despite being an unusual case, it should be suspected in a clinical exuberant as the patient, and must be properly treated, not only the bezoar itself, but the underlying cause that led to the ingestion of hair.

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...

Tricobezoar retal: relato de um caso raro na literatura / Rectal trichobezoar: report of a rare case in literature

O bezoar compreende o acúmulo de substâncias não-digeríveis (folhas, pêlos, pedras, produtos lácteos, medicamentos, entre outros) no trato digestório. Sua importância deve-se ao quadro clínico por vezes inespecífico e às complicações que podem surgir. Apresentamos aqui o caso de uma paciente de 62 anos atendida no serviço de Cirurgia Oncológica com quadro de um mês de evolução e suspeita inicial de neoplasia colorretal. Exames complementares não elucidaram o diagnóstico, que só foi feito após abordagem cirúrgica por laparotomia exploratória. Após a mesma, a paciente evoluiu com piora do estado geral e foi transferida para a UTI do hospital, falecendo devido a complicações septicêmicas. Esse caso demonstra as dificuldades para se chegar nesse diagnóstico e que o atraso pode resultar em complicações letais para o paciente.

Bezoar is a foreign body in the digestive tract originated from ingestion of non-digestible substances (leaves, hair, rocks, milk products, drugs, etc). Undetermined clinical signs and severe complications make it an important diagnosis. We report the case of a 62-year-old female patient who was seen at the oncological surgery department of Santa Casa de Misericórdia de Fortaleza. The patient reported having low gastrointestinal symptoms for a month. Colorectal neoplasia was initially suspected. Blood and image diagnostic tests were not elucidative. The diagnosis was just confirmed after surgical approach. The patient had a poor postoperative follow-up and died after complications of septicemia. This case demonstrates the difficulties to confirm such diagnosis and the lethal complications caused by diagnosis delay.

Terminal ileum perforation secondary to an impacted phytobezoar: case report / perforación del ileon terminal por un fitobezoar impactado: reporte de caso

Bezoars are concretions of undigested food particles, medications, milk formulas and hair. The most common presentation of a bezoar is in the form of a phytobezoar, which is caused by precipitation of undigested particles of vegetables and seeds. Small bowel obstruction is mainly caused by adhesions from previous surgery. Of all causes of intestinal obstruction, phytobezoars are responsible for only 0.4-4% of all causes. They are mainly precipitated by previous strictures caused by surgery, partial gastrectomy, Crohn’s disease or intestinal tuberculosis. Symptoms can range from a vague abdominal discomfort to nausea, early satiety, vomiting, halitosis and weight loss. Perforation is a rare complication in an intact abdomen because patients seek early medical treatment before this occurs. We describe the case of an 85 year old male patient, who presented with perforation of the terminal ileum, caused by an impacted phytobezoar and caused a localised abscess that was successfully treated with surgery.

Los bezoares son concreciones de porciones de alimento no digerido, medicamentos, fórmulas de leche o cabello. La presentación más común del bezoar es en la forma de fitobezoar, el cual es causado por la acumulación de partículas sin digerir de verduras y semillas. La obstrucción del intestino delgado es causada principalmente por adherencias de anteriores cirugías. Los fitobezoares son responsables de sólo 0,4-4% de todas las causas de obstrucción intestinal. Tales obstrucciones son principalmente provocadas por estenosis anteriores secundarias a cirugía, gastrectomía parcial, enfermedad de Crohn o tuberculosis intestinal. Los síntomas pueden variar desde una molestia abdominal vaga hasta náuseas, saciedad precoz, vómitos, mal aliento y pérdida de peso. La perforación es una complicación poco frecuente en un abdomen intacto, porque los pacientes buscan tratamiento médico temprano antes de que esto ocurra. Se describe el caso de un paciente de 85 años de edad, que se presentó con perforación del íleon terminal, causada por un fitobezoar impactado que le causó un absceso localizado, el cual fue tratado con éxito mediante cirugía.

Tricobezoar na infância: relato de três casos e revisão da literatura / Trichobezoar in children: report of three cases and review of literature

Tricobezoares são corpos estranhos gástricos compostos por cabelos dos próprios pacientes. São mais comuns em crianças, principalmente do sexo feminino. Cursam freqüentemente com sintomas gastrintestinais como dor abdominal, náuseas, vômitos, anorexia, perda de peso e plenitude pós-prandial. Massa epigástrica, alopécia e antecedentes de tricofagia podem estarpresentes. O tratamento de eleição é o cirúrgico, acompanhado de tratamento psiquiátrico. Este trabalho tem como objetivo relatar três casos de pacientes com tricobezoar gástrico e realizar uma revisão da literatura. Todos os casos deste estudo eram de crianças dosexo feminino. Dois pacientes cursaram com quadro de suboclusão intestinal, apresentando dor abdominal evômitos. Em um caso havia dor abdominal não acompanhada por vômitos. Todos apresentaram antecedentes de tricofagia, bem como massa epigástrica palpável. Um com áreas de alopécia. O principal examede imagem empregado foi a seriografiaesofagogastroduodenal. Todos foram submetidos a tratamento cirúrgico mediante gastrotomia e encaminhados para serviço de psicologia, com boaevolução clínica.

Trichobezoars are concretions of ingested hair that most often lodge in the stomach. They are commonlyseen in young girls with psychiatric disorders. Upper gastrointestinal symptoms usually are progressive andmay include abdominal pain, nausea and vomiting, early satiety, weight loss, bloating, diarrhea or constipation. Ahistory of tricophagia is common. Physical examination may include the presence of nontender palpable massand bald spot. Gastric trichobezoars require removal through an anterior gastrotomy. Postoperatively, psychiatric intervention is often appropriate. The purpose of this study was to describe three cases of patients with gastric trichobezoar and make a review of literature. All patients studied were yo ung girls. Two patients presented abdominal pain and vomiting. In one case there was abdominal pain without vomiting. All cases presented tricophagia and palpable mass. One had bald spot. Barium contrast study was the most beneficial in the diagnosis. In our cases, bezoars were removed easily via single gastrotomy. Postoperatively they were evaluated by psychology. The remainder of their hospital course wasunremarkable.

Tricobezoar gástrico e intestinal en adolescente femenina de 15 años: a propósito de un caso clínico IVSS "Dr. Tulio Carnevali Salvatierra" Mérida-Venezuela / Gastric and intestinal trichobezoar female teenager about 15 years: a purpose of case clinical in IVSS Dr. Tulio Carnevali Salvatierra

Los tricobezoar son recolecciones de material ingerido (pelos, fibras) que se acumulasn en estómago e intestino. Se originan de la tricotilomanía más tricofagia, cuando el tricobezoar se acumula en duodeno recibe el nombre de Sídrome de Rapunzel, más frecuente en el sexo femenino. Adolescente de 15 años, quien presentó dolor abdominal de aparición insidiosa acompañada de naúseas y vómitos incontables que se irradian a hipocondrio y fosa iliaca izquierda, su evolución fue torpida presentando signos de irritación peritoneal. Se realiza laparatomía exploradora hallándose tumor de contenido de pelo a nivel del Ángulo de Treitz, y cámara gástrica. Siendo egresada y referida al servicio de psiquiatría infanto-juvenil.

Plasticobezoar-another new entity for Rapunzel syndrome.

Rapunzel syndrome- a form of trichobezoar occurs when a gastric trichobezoar extends beyond the pylorus into the bowel. We report two cases of Rapunzel syndrome, one of them caused by ingestion of plastic material, so as to name it as a 'Plasticobezoar'. To the best of our knowledge no Rapunzel syndrome due to this material has been reported so far.