A trichobezoar is mass trapped in the gastrointestinal (GI) system formed from the ingestion of hair. It is a rare condition typically found in young females with concurrent psychiatric disorders [1]. Initially, the mass is asymptomatic; however, human hair cannot be digested due to its smooth surface and will eventually accumulate between the stomach’s mucosal folds [2]. Most trichobezoars are contained within the stomach. In some cases, known as Rapunzel syndrome, the trichobezoar can extend past the duodenum and cause intestinal obstruction. Small trichobezoars can be removed with fragmentation via endoscopy. Larger trichobezoars are more difficult to completely remove endoscopically and are more often removed surgically. Here, we report the case of a 14-year-old female diagnosed with a large trichobezoar.

In this article, we present the case of a 14-year-old female with past medical history of oppositional defiant disorder who presented with a 6-week-history of abdominal pain, decreased appetite, and intermittent vomiting. Upper GI study with small bowel follow through was performed and showed large gastric filling defect consistent with bezoar that extended into duodenum, causing duodenal obstruction. Pediatric surgery was consulted to remove bezoar. Upper endoscopy was attempted initially, which showed the bezoar. Several attempts were made to remove it piece by piece; however, with traction on the midpoint, it became evident that it would not pass the gastroesophageal (GE) junction without potentially disrupting the esophagus. The procedure was converted to exploratory laparotomy with gastrostomy. The bezoar and the long duodenal component were removed through the gastrostomy. Gross pathology of specimen (Figure 1) appeared as a well-circumscribed portion of hair measuring 7.5 × 6.0 × 2.8 cm. Loosely attached was a portion of hair-bearing material measuring 8.0 × 6.5 × 1.5 cm. The patient recovered well after surgery, diet was gradually increased, and abdominal pain improved. She was discharged five days post-op for regular outpatient follow-up with pediatric surgery, pediatric gastroenterology, and counseling services.

Gastric trichobezoar formation occurs primarily in adolescent patients with an irresistible urge to pull hair from the scalp (trichotillomania) combined with a desire to ingest hair (trichophagia). This hair becomes matted once swallowed and assumes the shape of the digestive tract. Bezoars can extend anywhere from the esophagus to the ileocecal junction and have presentations ranging from asymptomatic masses to emergent obstruction and perforations [1]. Endoscopic removal of the bezoar may be feasible in smaller masses; however, there is increased risk of incomplete removal as the tail of the bezoar extends further into the digestive tract. Furthermore, removal of the trichobezoar fragments requires repeated introduction of the endoscope, which carries the risk of esophageal ulceration and perforation [2]. Laparotomy is a viable treatment option for large trichobezoars. In addition to surgical removal, psychiatric counseling in these patients is necessary to prevent relapse [2].

Gastric trichobezoars are rare and most often occur in young females. They are typically contained in the stomach but can extend into the small intestine. Ideally, small trichobezoars are diagnosed and removed endoscopically. With larger trichobezoars, the risk of incomplete removal and possible esophageal disruption makes surgical removal a more feasible option. Psychiatric consultation should be initiated following removal to prevent relapse.