Gastric masses {Trichobezoar with Rapunzel Syndrome}

Discussion:
Both patients had history of trichophagia and the second patient also had history of eating nails. The mass removed was trichobezoar. A trichobezoar is a conglomerate of trapped hair mainly originating in the stomach. {1,2} It is seen in young females. {1,2} The hair being enzyme-resistant and smooth, cannot be digested and accumulates between the gastric mucosal folds leading to formation of a hair ball together with entrapped food and mucus. {1,3} It is commonly associated with mental retardation and psychiatric disturbances like trichotillomania and trichophagia predominantly seen in emotionally disturbed or mentally retarded youngsters. {1,2,4} Predisposing risk factors include delayed gastric emptying, prior gastric surgery, peptic ulcer disease, chronic gastritis, Crohn’s disease, carcinoma of the gastrointestinal tract, dehydration and hypothyroidism. {1,5,6}
Presentation can be asymptomatic or with dyspepsia, anorexia, nausea, vomiting, colicky abdominal pain, bowel disturbances and weight loss. {4} A palpable mobile mass in epigastric region may be present. {2} Complications include gastrointestinal bleeding {caused by ulceration in the gastric mucosa due to pressure necrosis induced by the bezoar}, perforation, gastric emphysema, iron deficiency and megaloblastic anemia mandating early removal. {1,2,4} An unusual form of bezoar extending from stomach to the small intestine or beyond has been described as Rapunzel syndrome {2} which was seen in our second patient. USG, contrast study of the gastrointestinal tract, CECT scan and endoscopy help in diagnosis. {1}
Removal by endoscopic fragmentation is generally ineffective in large trichobezoars. {1} Specialized bezotomes and bezotriptors have been reported to fragment large and solid trichobezoars. Surgical excision can be done by laparotomy, mini-laparotomy or by laparoscopic techniques. {1,2,4} Successful pharmacotherapy for bezoars with cola, papain and cellulose and prokinetic agents like itopride, mosapride and metoclopramide has been reported. {1,2} Parental counseling, appropriate psychiatric treatment and long-term follow-up are mandatory to prevent recurrence.

References :

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