Open Removal Of Massive Trichobezoar In A Patient With Rapunzel Syndrome #Surgery #Laparotomy

Trichobezoars are a rare cause of gastric outlet obstruction in the adult population. Most literature describes trichobezoars as a result of trichotillomania (compulsive hair pulling) and trichophagia (compulsive hair eating) in pediatric patients, or patients with developmental delay or psychiatric disorders. Rapunzel syndrome occurs when the trichobezoar extends to the small bowel or beyond. Herein, we present a case of massive trichobezoar requiring laparotomy for removal. The patient is a 25-year-old female with a history of adjustment disorder, anemia, chronic abdominal pain, and trichophagia who presented with one month of worsening abdominal pain, nausea and gastric distention. CT scan obtained in the ED revealed a massively distended stomach with intraluminal debris, concerning for mechanical gastric outlet obstruction. Abdominal exam was benign, with no rebound or guarding to deep palpation. Gastroenterology was consulted to attempt endoscopic retrieval, which was unsuccessful. Therefore, the patient was taken to the operating room for open removal. The trichobezoar was manually removed via a gastrotomy, found to be a large mass comprised of hair extending to the fourth portion of the duodenum. The gastrotomy was closed in two layers, and an NG tube left in place. The patient remained NPO until postoperative day 3, when an upper GI study revealed no leak. Her diet was slowly advanced, she regained bowel function, and she was discharged on postoperative day 5. She was discharged with psychiatry follow up to pursue cognitive behavioral therapy to prevent continued trichophagia.