Trichobezoar with duodenal perforation: a rare occurrence


  • Juin Yeen Ooi Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
  • Kean Leong Koay Department of General Surgery, Hospital Serdang, Selangor, Malaysia
  • Lilius Li Hui Tang Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
  • Ramamoorthy Velayutham Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia



Trichobezoar, Duodenal, Perforation


Trichobezoar is an intraluminal mass formed from the accumulation of undigested hair. It is a rare condition that is typically seen in young females with trichophagia and trichotillomania. When not recognized, it may present with complications such as obstruction, ulceration and in some rare cases, perforation. While most trichobezoar perforations are located in the stomach, however, duodenal perforation has not been reported before. We report a case of a 13-year-old girl who presented to the emergency with signs and symptoms of peritonitis and perforated viscus. Radiological investigation revealed a large heterogenous intraluminal mass with mottled gas pattern suspicious of bezoar. Oral contrast was seen tracking from the gastric pylorus into the peritoneum suggestive of a perforation. The girl was brought to theatre for emergency laparotomy and a trichobezoar was found extending from the stomach down to the level of D1. There is a perforation in D1 on its antero-superior surface measuring 1×1 cm. The bezoar was removed via a gastrostomy and the perforation was primarily repaired and patched with omentum. Post operatively, her recovery was complicated with wound breakdown and was subsequently discharged after 1.5 months of hospitalization with outpatient referral for psychiatry consults.


DeBakey M, Ochsner A. Bezoars and concretions. Surgery. 1939;4:934-63.

Nirasawa Y, Mori T, Ito Y, Tanaka H, Seki N, Atomi Y. Laparoscopic removal of a large gastric trichobezoar. J Pediatr Surg. 1998;33:663-5.

Coufal NG, Kansagra AP, Doucet J, Lee J. Gastric trichobezoar causing intermittent small bowel obstruction: report of a case and review of the literature. Case Rep Med. 2011;217570.

Marginean CO, Melit LE, Sasaran MO. Rapunzel Syndrome-An Extremely Rare Cause of Digestive Symptoms in Children: A Case Report and a Review of the Literature. Front Pediatr. 2021;9:684379.

Vaughan ED, Sawyers JL, Scott HW. The Rapunzel syndrome. An unusual complication of intestinal bezoar. Surgery. 1968;63(2):339-43.

Naik S, Gupta V, Naik S, Rangole AK, Jain P, Sharma AK. Rapunzel Syndrome Reviewed and Redefined. Dig Surg. 2007;24(3):157-61.

Kim SC, Kim SH, Kim SJ. Large Trichobezoar Causing Rapunzel Syndrome. Medicine. 2016; 95(22):e3745.

Tayyem R, Ilyas I, Smith I, Pickford I. Rapunzel syndrome and gastric perforation. Ann R Coll Surg Engl. 2010;92(1):e27-8.

Gorter RR, Kneepkens CMF, Mattens ECJL, Aronson DC, Heij HA. Management of trichobezoar: case report and literature review. Pediatr Surg Int. 2010;26(5):457-63.






Case Reports