Rapunzel syndrome (Trichobezoar) revisited from Gadchiroli: a case report and review of literature

Abstract

Trichobezoar, a concretion of swallowed hair within the gastrointestinal tract, is a rare condition that predominantly affects young females with trichotillomania and trichophagia; extension of the mass beyond the pylorus into the small intestine is termed Rapunzel syndrome. We present a 28-year-old married woman from Gadchiroli district, Maharashtra, with a one-year history of progressive epigastric heaviness and one month of worsening burning abdominal pain, early satiety and significant weight loss. She firmly denied hair-eating behavior, although her husband reported prolonged unusual irritability. Examination revealed a smooth, firm, well-defined 10×8 cm epigastric mass. Upper gastrointestinal endoscopy showed a large mass of matted hair occupying the stomach, and contrast-enhanced computed tomography (CECT) of the abdomen demonstrated a laminated, mixed-density intraluminal lesion without pyloric extension. She underwent elective open anterior gastrotomy with en-bloc removal of the trichobezoar, and examination of the entire small bowel excluded distal fragments. Recovery was uneventful. On psychiatric evaluation before discharge, she admitted to pulling and eating her own hair for about three years, and trichotillomania with trichophagia was diagnosed. Habit reversal therapy, cognitive-behavioral therapy and sertraline were initiated; at nine months her weight was well maintained, although adherence to psychiatric care was poor. Trichobezoar should be considered in any young woman presenting with an epigastric mass, irrespective of whether she admits to hair-eating. Endoscopy and CECT establish the diagnosis, and open anterior gastrotomy remains a safe, reproducible treatment for large lesions in resource-limited settings. Postoperative psychiatric care is the cornerstone of relapse prevention.