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    [Nephrotic syndrome in a female patient with Rapunzel syndrome]. Umbetalina N S,Turgunov E M,Turgunova L G,Baesheva T A,Bacheva I V Terapevticheskii arkhiv The Rapunzel syndrome is a rare complication of gastric trichobezoar, which may be long insidious. Systemic hair eating gradually leads to bezoar growth, gastritis, gastric mucosal ulcerations, and evacuatory disorders. The Rapunzel syndrome may cause acute and chronic bowel obstruction, peritonitis, pancreatitis, appendicitis, anemia, hypoalbuminemia, and allergic manifestations. Neither proteinuria nor nephrotic syndrome is depicted in any of the 38 Rapunzel syndrome cases described in the literature. The authors present the first case of gastric trichobezoar extending to the small bowel (its total length was 118 cm), which gave rise to chronic recurrent partial bowel obstruction, causing intoxication nephrotic syndrome in a 20-year-old women with trichotillomania. The nephrotic syndrome became a reason for her admission to a nephrology department and had specific features: it was unaccompanied by hypercholesterolemia, it rapidly regressed and completely disappeared after surgical removal of the trichobezoar weighing 1980 g. 10.17116/terarkh2014861278-80
    A modern form of Rapunzel syndrome: trichobezoar composed of synthetic hair extensions. Kwong Wilson T,Kalmaz Denise Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 10.1016/j.cgh.2014.01.036
    Rapunzel syndrome: diagnosis via radiograph and history. Belsky Justin,Whitcomb Valerie,Zimmerman Eric,Stankovic Curt Pediatric emergency care Rapunzel syndrome is defined as a gastric trichobezoar with a tail that extends distally into the small intestine. It is extremely rare and found more often in premenarchal girls with psychiatric comorbidities. Symptoms can be vague and linger for years. However, prolonged intake of indigestible material can lead to gastric outlet obstruction, which may present similarly to a small bowel obstruction. The standard imaging modality of choice to make a presurgical diagnosis is via computed tomography (CT) scan of the abdomen. However, the risk of radiation-induced malignancy associated with a CT scan is an important consideration when managing children. We report a case of Rapunzel syndrome in a 6-year-old girl who was diagnosed presurgically without the use of a CT scan. 10.1097/PEC.0000000000000129
    A rare outcome of iron deficiency and pica: Rapunzel syndrome in a 5-year-old child iron deficiency and pica. Islek Ali,Sayar Ersin,Yılmaz Aygen,Boneval Cem,Artan Reha The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology Bezoar is defined as the accumulation of organic or nonbiological substances inside the gastrointestinal system. Trichobezoars are the most frequently detected ones and are mostly present in patients with neuropsychiatric disorders. The continuance of the trichobezoar tail-shaped extension over the duodenum and jejunum is described in Rapunzel syndrome. Both conditions are rarely reported in children. The present case submitted here is related to a 5-year-old girl referred with an abdominal mass and anemia, diagnosed with Rapunzel syndrome and developing trichobezoar due to iron deficiency and pica. 10.5152/tjg.2014.4051
    Rapunzel syndrome: a rare presentation with giant gastric ulcer. Athanasiou Antonios,Michalinos Adamantios,Moris Demetrios,Spartalis Eleftherios,Dimitrokallis Nikolaos,Kaminiotis Vaios,Oikonomou Demetrios,Griniatsos John,Felekouras Evangelos Case reports in medicine The Rapunzel syndrome refers to an uncommon and rare form of trichobezoar that extends past the stomach into the small intestines. The Rapunzel syndrome is usually found in young female patients with a history of psychiatric disorders, mainly trichotillomania and trichophagia. We describe a case of Rapunzel syndrome in a 15-year-old girl who presented with abdominal pain, vomiting, and weight loss. We performed a surgical laparotomy and successfully removed a huge trichobezoar extending into the small intestine. 10.1155/2014/267319
    Extremely unusual case of gastrointestinal trichobezoar. Jatal Sopan N,Jamadar Nawab P,Jadhav Bhagwat,Siddiqui Saleha,Ingle Sachin B World journal of clinical cases Trichobezoars (hair ball) are usually located in the stomach, but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome). Rapunzel syndrome remains uncommon; with fewer than 40 cases reported. To the best of our knowledge, this case may be the first well-documented case with a length of 75 cm. They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. In the literature several treatment options are proposed, including removal by conventional laparotomy, laparoscopy and endoscopy. Herein, we are reporting an interesting case of an 18-year mentally retarded girl with history of trichotillomania and trichophagia who presented to our emergency department with a history of central abdominal pain associated with vomiting and constipation for five days. An examination showed a trichobezoar requiring emergent surgical intervention, and indicating the need for psychiatric treatment. The trichobezoar was treated successfully by laparoscopy. 10.12998/wjcc.v3.i5.466
    Rapunzel syndrome presenting as jejuno-jejunal intussusception. Marwah Sanjay,Pandey Siddharth,Raj Abhishek,Jangra Mahavir Singh,Sharma Himanshu Clinical journal of gastroenterology The term Rapunzel syndrome is used to describe a trichobezoar of the stomach with a long tail of hair extending into the duodenum and small intestine. It is a rare clinical entity, and it is even rarer in these cases that jejuno-jejunal intussusception and resulting intestinal obstruction is a presenting feature. We report one such case, a young female who presented in the emergency department with abdominal pain and bilious vomiting of short duration. Contrast-enhanced CT of the abdomen enabled a diagnosis of a trichobezoar in the stomach extending into the small gut, along with jejuno-jejunal intussusception. On exploration, gastrotomy was performed to remove the gastric trichobezoar, and jejuno-jejunal intussusception was found on three segments in the proximal jejunum, which was resolved upon complete removal of the tail of the bezoar. This case report is unusual, since intussusception is a rare occurrence in Rapunzel syndrome, and this is the first time that it has been diagnosed preoperatively. 10.1007/s12328-015-0578-7
    Uncommon Presentation of Gastric Trichobezoar: A Case Report. Zeraatian Sam,Ameri Sara,Tabesh Hanif,Kamalzadeh Nazafarin Iranian journal of public health Every material that gastrointestinal system cannot digest will make a bezoar. Trichobezoar is the result of hair ingestion whether self-hair or from others and is not a common disorder in humans. It is a hairball, which mostly has been seen in females at teenage, or adolescence. It usually locates in stomach but in rare conditions, it will pass through the intestine, and make the Rapunzel syndrome. Herein we present a 13-year-old girl suffering from gastric trichobezoar presenting with failure to thrive.
    Rapunzel syndrome due to ingested hair extensions: Surgical and psychiatric considerations. Flaherty Devin C,Aguilar Francis,Pradhan Basant,Grewal Harsh International journal of surgery case reports INTRODUCTION:Rapunzel syndrome is a unique clinical manifestation of trichotillomania and trichophagia. The resulting gastric trichobezoar can be massive and necessitate surgical extraction. PRESENTATION OF CASE:We present a case involving a 15 year-old female with a known history of trichotillomania. The patient possessed symptoms of nausea and early satiety, and admitted that she had recently consumed a large number of hair extensions. Computed tomography imaging revealed a massive gastric bezoar not amenable to endoscopic extraction. The patient underwent surgical laparotomy, and a large gastric trichobezoar was removed through an anterior gastrotomy. The trichobezoar extended past the pylorus into the duodenum, thus confirming a diagnosis of Rapunzel syndrome. DISCUSSION:Trichobezoars formed from the consumption of hair extensions is a rare cause of Rapunzel syndrome. Surgical extraction is often necessitated due to the sheer size of the gastric bezoar that results from consuming hair extensions. If not previously established, psychiatric consultation should be pursued in the immediate post-operative course as these patients may require pharmacologic management along with behavioral therapy to avoid further episodes of trichotillomania. CONCLUSION:This case presents a unique and modern manifestation of Rapunzel syndrome. Surgical treatment most often is required when a patient presents with a massive gastric trichobezoar. Regular post-operative psychiatric follow-up is necessary to prevent recurrent episodes. 10.1016/j.ijscr.2015.11.009
    Rapunzel syndrome: A rare cause of abdominal pain. Beristain-Silva J L,Cordero-Barberena R,Beristain-Hernández J L Revista de gastroenterologia de Mexico 10.1016/j.rgmx.2015.08.005
    Gastric Trichobezoar with Rapunzel Syndrome: A Case Report. Dixit Anoop,Raza Mohd Arshad,Tiwari Rohit Journal of clinical and diagnostic research : JCDR Bezoars are collections of non-digestible matter that usually accumulates in stomach and can extend to small bowel. Trichobezoars (concretions of hair) are unusual and are usually found in young psychiatric females, who often deny eating their own hair (trichophagy). We are presenting a case of gastric trichobezoar with a long thin tail in a 20 years young female with a history of trichophagia. Patient was managed by exploratory laparotomy and anterior gastrotomy. Postoperatively she recovered well and was discharged in satisfactory condition with advice for psychiatric follow-up. 10.7860/JCDR/2016/17245.7211
    [Rapunzel syndrome with multiple small-bowel intussusceptions: An unusual association of trichobezoar]. Mnari W,Maatouk M,Hmida B,Zrig A,Abdellatif N,Golli M Archives de pediatrie : organe officiel de la Societe francaise de pediatrie 10.1016/j.arcped.2016.03.017
    Rapunzel Syndrome: Rare 'Tale' of a Broken 'Tail'. Chauhan Narvir S,Kumar Satish,Bhoil Rohit Polish journal of radiology BACKGROUND:Rapunzel syndrome is a rare and unique form of trichobezoar, in which a cast of hairs is formed in the stomach with its 'tail' extending up to varying lengths into the small bowel. Almost all cases described in literature are of 'classic' and more common form of Rapunzel. Sometimes however, the tail of bezoar is broken into smaller fragments. There is not much literature available on this rarer subset of Rapunzel syndrome. CASE REPORT:In this report we present the ultrasound (USG) and CT findings of a case of Rapunzel syndrome in which the tail had broken into five separate fragments. The patient presented clinically with intestinal obstruction due to the impaction of the distal- most fragment in the ileum. CONCLUSIONS:Our case highlights the fact that although USG features may be suggestive, a careful evaluation of CT images is essential for a confidant preoperative diagnosis of Rapunzel syndrome. In cases of this syndrome with a broken tail, CT is essential for precise count and localization of the separated fragments to ensure their complete removal at the time of surgery. We also propose to name the fragments of the broken tail as 'bezoarlets'. This word aptly describes the tail fragments as it suggests their origin from the larger gastric bezoar and the suffix 'lets' conveys they are smaller in size. 10.12659/PJR.896154
    A Case Report: Large Trichobezoar Causing Rapunzel Syndrome. Kim Soon Chul,Kim Seong Hun,Kim Sun Jun Medicine Rapunzel syndrome is very rare gastric foreign bodies that occur in children. It is a severe condition of a gastric trichobezoar with a long tail that passes into the small intestine. Here, we present the case of an 8-year-old girl with Rapunzel syndrome due to a very large (7 × 7 × 30 cm) gastric trichobezoar. The patient had trichotillomania and trichophagia for 1 year prior to presentation. Ideally, small bezoars are removed through a minimally invasive method, such as endoscopic fragmentation. However, large trichobezoars, including those in Rapunzel syndrome, can only be managed with open surgical extraction, despite the large scars that may result.We report a case of Rapunzel syndrome with a large bezoar that was surgically removed after it was endoscopically cauterized with argon plasma. Endoscopic precutting was used to effectively reduce the size of the bezoar. 10.1097/MD.0000000000003745
    Rapunzel syndrome in a seven year old female. Gupta Anand,Kaur Jaswinder,Wadhwa Nishant The Turkish journal of pediatrics Rapunzel syndrome is characterized by gastric trichobezoar with extension beyond pylorus. Seven year old female presented with chronic pain abdomen and loss of appetite. Upper gastrointestinal (UGI) endoscopy showed large trichobezoar in the stomach with its tail extending into proximal duodenum. Child underwent exploratory laparotomy and a large trichobezoar measuring 15 cm was removed. Psychiatric opinion revealed that the child was suffering from `trichotillomania`; an obsessive compulsive disorder. UGI endoscopy is the preferred modality for diagnosis, as it delineates the mass and its extent. Small bezoars can be extracted via endoscopy using various disintegrating techniques but large bezoars need surgical management. 10.24953/turkjped.2017.05.016
    Rapunzel syndrome is not just a mere surgical problem: A case report and review of current management. Obinwa Obinna,Cooper David,Khan Faraz,O'Riordan James M World journal of clinical cases Recurrent Rapunzel syndrome (RRS) is a rare clinical presentation with fewer than six cases reported in the PubMed literature. A report of RRS and literature review is presented. A 25-year-old female was admitted to hospital with a 4-wk history of epigastric pain and swelling. She had a known history of trichophagia with a previous admission for Rapunzel syndrome requiring a laparotomy nine years earlier, aged 16. Psychological treatment had been successfully achieved for nine years with outpatient hypnotherapy sessions only, but she defaulted on her last session due to stressors at home. The abdominal examination demonstrated an epigastric mass. Computer tomography scan revealed a large gastric bezoar and features of aspiration pneumonia. The patient underwent emergency open surgical laparotomy for removal as the bezoar could not be removed endoscopically. The bezoar was cast in a shape that mimicked the contours of the stomach and proximal small bowel, hence the diagnosis of RRS. The patient was seen by a psychiatrist and was commenced on Quetiapine before discharge. She continues to attend follow-up. 10.12998/wjcc.v5.i2.50
    Trichobezoar (Rapunzel Syndrome) Causing Severe Anaemia and Cardiac Failure. Sailer Sebastian,de Carlos Vicente Juan Carlos,García Andrea Álvarez,de la Concepción Barceló Cañellas Maria,Zibetti Sara,Calvar Amelia González Klinische Padiatrie 10.1055/s-0043-104219
    Trichobezoar with and without Rapunzel syndrome in paediatric population: A case series from a tertiary care centre of Northern India. Kajal Pradeep,Bhutani Namita,Tyagi Niharika,Arya Pratibha International journal of surgery case reports INTRODUCTION:Trichobezoars are concretions formed by accumulation of hair in stomach. Usually, trichobezoar is confined to the stomach, but rarely it may extend from the stomach to the small intestine and even colon. This is an unusual form called Rapunzel syndrome. Our experience with this rare entity of Rapunzel syndrome and interesting entity of trichobezoar is being presented with review of literature. PRESENTATION OF CASES:We, at our institute, encountered four cases of trichobezoar in last five years, out of which two were found to be of Rapunzel syndrome. All of these cases were managed successfully by open surgical intervention in view of the very large size of the mass in all the cases. DISCUSSION:The clinical presentation is highly variable ranging from asymptomatic cases diagnosed incidently to serious gastrointestinal symptoms and complications. Cases of trichobezoar have been reported in literature very infrequently but Rapunzel syndrome is extremely rare and less than 50 cases have been reported in medical literature till date. CONCLUSION:Trichobezoar leading to Rapunzel syndrome is an extremely rare entity. The clinical presentation is usually vague and non-specific. Treatment is mainly surgical because of delayed presentation in majority of the cases. Psychiatric illness is the usual association. 10.1016/j.ijscr.2017.08.060
    A novel finding of Rapunzel syndrome. Iwama Itaru,Nambu Ryusuke,Hara Tomoko Clinical journal of gastroenterology Rapunzel syndrome is a rare form of gastric trichobezoar (hair ball) involving extension of a tail of the hair into the small bowel. A 13-year-old girl was admitted with a 4-day history of epigastric pain and nausea which worsened after meals. Abdominal ultrasound showed duodenal wall thickening and lymphadenopathy. Esophagogastroduodenoscopy identified a gastric trichobezoar with a tail extending into the duodenum. In addition, multiple longitudinal duodenal and jejunal ulcers were noted. The ulcers appeared to be a result of direct pressure by the tail itself against the intestinal mucosa. The trichobezoar was successfully retrieved endoscopically under general anesthesia. Her symptoms resolved completely after retrieval. Psychiatric follow-up was carried out to help reduce the risk of recurrence. Here, we describe a novel complication of Rapunzel syndrome, i.e., multiple longitudinal ulcers of the small intestine. This novel finding suggests that the mucosal damage caused by the trichobezoar of Rapunzel syndrome can occur in an earlier stage than previously thought. In addition, we also strongly recommend using general anesthesia with intubation when removing a gastric trichobezoar to ensure protection of the airway. 10.1007/s12328-017-0790-8
    Rapunzel Syndrome. Lalith Sneha,Gopalakrishnan Karunya Lakshmi,Ilangovan Gurubharath,Jayajothi Anandapadmanabhan Journal of clinical and diagnostic research : JCDR A bezoar refers to a mass of undigestible foreign material found in the gastrointestinal tract, mainly stomach. The second most common bezoar is the trichobezoar, which usually occurs in the young psychiatric female patients with history of trichotillomania and trichophagia. This is a case report of a 12 -year-old female patient came with complaints of diffuse abdominal pain, vomiting, and constipation. Ultrasound, Barium X-ray and Computed Tomography scan were done, which suggested trichobezoar. Thus, trichobezoar should be considered as differential diagnosis of abdominal pain in young female patients with associated psychiatric complaints. A review is presented here, as a high index of suspicion for better diagnostic facilities which can help in timely diagnosis and intervention, to prevent further complications like intestinal obstruction, perforation and mortality in such children. 10.7860/JCDR/2017/28593.10594
    Trichobezoar and Rapunzel syndrome : an unusual cause of abdominal mass. O'Flynn L,Disney B R,Menon V,Mannath J Acta gastro-enterologica Belgica
    The cause of abdominal mass in a child with celiac disease: Rapunzel syndrome. A case report. Appak Yeliz Çağan,Ertan Duygu,Karakoyun Miray,Özyurt Gonca,Özdemir Tunç,Baran Maşallah Sao Paulo medical journal = Revista paulista de medicina CONTEXT:Rapunzel syndrome is a rare form of gastric trichobezoar that develops through outstretching of the bezoar from the stomach to the intestine. CASE REPORT:A 12-year-old girl who had been diagnosed with celiac disease six years earlier was brought to the department of pediatric gastroenterology because of abdominal distension. A palpable mass was detected. A trichobezoar that stretched to the small intestine was removed surgically. The patient was diagnosed as having anxiety and depressive disorder, and treatment started. Following the treatment, her previous trichophagia completely disappeared. CONCLUSION:Presence of trichobezoar should be kept in mind, especially when young girls who have psychiatric problems suffer from gastrointestinal symptoms. 10.1590/1516-3180.2017.0281141017
    Rapunzel syndrome: an infrequent cause of severe iron deficiency anemia and abdominal pain presenting to the pediatric emergency department. Cannalire Giuseppe,Conti Luigi,Celoni Maurizio,Grassi Carmine,Cella Andrea,Bensi Giulia,Capelli Patrizio,Biasucci Giacomo BMC pediatrics BACKGROUND:Iron deficiency anemia (IDA) and abdominal pain are commonly seen in a pediatric emergency department (8 and 18% incidence respectively in our center). They are manifestations of a wide variety of diseases ranging from benign to immediately life-threatening. Trichobezoar is an under-diagnosed entity that has to be considered in children and adolescents, expecially female, suffering from trichotillomania (compulsion to pull hair) and trichophagy (compulsion to swallow hair). When undiagnosed, gastric bezoars may cause gastric ulceration, perforation, haemorrhage and obstruction. CASE PRESENTATION:To underline the importance of including this pathology in the differential diagnosis of IDA and abdominal pain, we present the case of a 14 year-old girl with a huge trichobezoar which completely filled the stomach and extended into the small bowel. Since trichobezoar has an extension to the small bowel, it is classified as Rapunzel syndrome. As the bezoar couldn't be removed by endoscopy, the girl underwent surgical intervention. The patient passed through a gradual re-feeding, with iron and vitamins supplementation, and through a psychiatric counselling. CONCLUSION:The Rapunzel syndrome is a rare entity that may be complicated by life-threatening events. A prompt diagnosis and an appropriate therapy can reduce comorbidities. Gradual re-feeding with supplementation of micronutrients allows adequate catch-up weight with normalization of haematochemical nutritional parameters. Since many of these patients suffer from psychiatric pathology such as PICA with emotional problems and mental retardation, psychological/psychiatric counselling plays an important role in order to prevent bezoar recurrence. 10.1186/s12887-018-1097-8
    Rapunzel syndrome: a tail too long to tell! Khanna Kashish,Tandon Sarvesh,Yadav Devendra Kumar,Khanna Vikram BMJ case reports 10.1136/bcr-2018-224756
    Rapunzel syndrome with double simultaneous trichobezoar in a teenager: Clinical Case Report. Bargas Ochoa Miguel,Xacur Hernández María,Espadas Torres Mariela,Quintana Gamboa Alexis,Tappan Lavadores Iddar,Méndez Domínguez Nina Revista chilena de pediatria Resumen: Introduction: Trichobezoars are an intraluminal accumulation of ingested hair. The Rapunzel syndrome refers to the presence of gastric trichobezoars which extend to the small intestine together with trichotillomania and trichophagia, that occur predominantly in psychiatric patients of pediatric age. OBJECTIVE:To analyze the clinical course and resolution of this syndrome in a case report. Likewise, we provide information about the family environment and psycho-emotional context of the patients and help the reader identify similar circumstances in their clinical practice. CASE REPORT:Female 14-year-old patient with history of trichotillomania and trichophagia of two years of evolution, who consulted for epigastric pain associated with weight loss, nausea, and postprandial fullness. During the physical examination, the patient was found to have bald patches in the scalp along with a palpable mass that seemed to be confined to the gastric limits. Imaging studies revealed gastric occupation due to a bezoar formation. The patient was treated surgically with laparotomy and gastrostomy, and two simultaneous trichobezoars were removed from the patient´s stomach and duodenum, the patient also underwent psycho-emotional professional counseling. CONCLUSION:Rapunzel´s syndrome, far for being a merely surgical entity, also requires psychoemotional assessment to prevent it recurrence and limit its severity. 10.4067/S0370-41062018000100098
    The curious case of Rapunzel syndrome: a rare non-Trichobezoar. Rogers Hayley K,Phadke Omkar,Glaser Andrea M The American journal of gastroenterology 10.1038/s41395-018-0018-7
    Trichobezoar: Ravenous for Hair. Prasad Akshay,Jain Atul,Gupta Akash,Kamra Aman Euroasian journal of hepato-gastroenterology Trichophagia is the habit of chewing hair. On an average, only 1% patients with trichophagia develop trichobezoar. They are usually symptomless until they reach a large size. It is common in young females usually with an underlying psychiatric disorder. The gold standard for diagnosis is upper gastrointestinal endoscopy (UGIE). Here we present a case of trichobezoar in an 11-year-old girl who presented in the emergency with complaint of pain abdomen and symptoms of obstruction. Key messages:A high index of suspicion among physician can lead to early diagnosis and management in these cases (trichobezoar). Prasad A, Jain A, Gupta A, Kamra A. Trichobezoar: Ravenous for Hair. Euroasian J Hepato-Gastroenterol 2018;8(1):97-98. 10.5005/jp-journals-10018-1271
    Rapunzel syndrome: A South African variety. Plaskett J,Chinnery G,Thomson D,Thomson S,Dedekind B,Jonas E South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde Trichobezoars are intraluminal accretions of ingested hair. Rapunzel syndrome is a rare and extreme presentation, with the trichobezoar extending into the small intestine. It is most frequently reported in children and psychiatric patients. We report a South African series of 5 patients who presented with trichobezoars. Each patient was retrospectively reviewed and analysed with regard to background, demographics, clinical presentation, diagnosis, surgical management and complications. Five female patients with a median age of 19 (range 12 - 27) years presented with clinical symptoms, including early satiety, intermittent vomiting with gastric outlet obstruction, abdominal pain and weight loss. The diagnosis was made by endoscopy, abdominal computed tomography (CT) imaging, barium meal examination or plain abdominal radiography. Two patients presented with sealed/contained gastric perforations, and 1 patient with a small-bowel perforation. All 5 bezoars, 2 of which consisted entirely of artificial hair extensions, extended into the jejunum, the longest measuring 1.4 m. All were removed by laparotomy. While trichobezoars are a rare entity, they may present with significant complications, such as obstructions and perforations. In view of the infection risk and considerable size of many of these bezoars, an open removal is probably safer than any minimally invasive attempt. 10.7196/SAMJ.2018.v108i7.13115
    Rapunzel syndrome: how to orient the diagnosis. Finale Enrico,Franceschini Piergiorgio,Danesino Cesare,Barbaglia Michelangelo,Guala Andrea Pediatric reports Rapunzel syndrome is a rare form of tricobezoar with a tail extending from the stomach into the small bowel; surgical removal is generally required. About 60 cases have been reported and described in the literature since 1968. We present the case of an 8-year-old girl who, during the course of a genetic consultation, was initially assigned with a clinical suspicion of ectodermal dysplasia. Surgical intervention, which resulted in the extraction of a tricobezoar of enormous size and extension, led us to the diagnosis of Rapunzel syndrome. The possibility of a tricobezoar should be considered in all cases of adolescent patients who present signs of intestinal occlusion or sub-occlusion, suffer from psychiatric disorders, and have a history of trichotillomania. Endoscopic methodology, medical imaging and clinical diagnostics are fundamental for a differential diagnosis. Psychiatric follow-up is advised to prevent recurrence. 10.4081/pr.2018.7689
    Rapunzel syndrome: a rare form of trichobezoar in the stomach with some extension into the small intestine. Blejc Novak Anja,Zupančič Živa,Plut Domen,Gvardijančič Diana,Homan Matjaž Acta dermatovenerologica Alpina, Pannonica, et Adriatica Trichobezoars are gastric foreign bodies rarely found in children. They are mainly composed of swallowed hair. Rapunzel syndrome is a very rare form of trichobezoar characterized by extension of the ingested hair from the stomach into the small intestine or even beyond. Clinical presentation can range from an asymptomatic abdominal mass to severe symptoms: gastric outlet obstruction, perforation of the stomach, and acute pancreatitis. Trichobezoars are usually treated with surgical removal. Here we present the case of an 8-year-old girl in whom a firm non-tender mass in the epigastric region was palpated during a regular outpatient clinic visit. The girl reported some slight abdominal discomfort and early satiety during meals. Subsequently, focal alopecia was detected. A trichobezoar in the stomach with some extension into the duodenum was diagnosed by ultrasound, and later confirmed by a barium swallow study and CT scan. The trichobezoar was successfully surgically removed.
    Small-Bowel Obstruction Secondary to Ileal Trichobezoar in a Patient with Rapunzel Syndrome. García-Ramírez Bertha E,Nuño-Guzmán Carlos M,Zaragoza-Carrillo Ricardo E,Salado-Rentería Hugo,Gómez-Abarca Audrey,Corona Jorge L Case reports in gastroenterology Bezoars are conglomerations of undigested foreign material retained in the gastrointestinal tract. Trichobezoar is a compact conglomeration of swallowed hair and constitutes less than 6% of all bezoars. Their most frequent location is in the stomach but they may extend through the pylorus into the small bowel. This condition is known as Rapunzel syndrome. Many patients may remain asymptomatic or present a mild form of the disease characterized by abdominal pain, early satiety, nausea, and vomiting. Complications may manifest as gastric outlet obstruction or bleeding, and intestinal obstruction. A 15-year-old female patient presented with clinical findings of intestinal obstruction. The patient suffered from depressive and anxiety disorders and trichotillomania, although trichophagy could not be assured. Alopecia circumscripta and irregular hair length on the scalp were identified. A computed tomography (CT) scan showed two images highly suggestive of trichobezoars, one in the stomach and the second one causing obstruction at the ileocecal valve. At laparotomy, both a mobile gastric trichobezoar with a tail extending to the duodenum and a trichobezoar causing obstruction at the ileocecal valve were removed. The postoperative course was uneventful. The passage of a detached trichobezoar fragment in a patient with Rapunzel syndrome may cause intestinal obstruction. CT is the preferred image modality for the evaluation of suspected trichobezoars in order to characterize their size and locations, the presence and level of obstruction, and complications such as ischemia or perforation. A case of small-bowel obstruction secondary to ileal trichobezoar in a patient with Rapunzel syndrome is herein reported. 10.1159/000492810
    Surgical outcome of jejunum-jejunum intussusception secondary to Rapunzel syndrome: a case report. Bolívar-Rodríguez Martín Adrián,Fierro-López Rodolfo,Pamanes-Lozano Adrián,Cazarez-Aguilar Marcel Antonio,Osuna-Wong Benny Alonso,Ortiz-Bojórquez José Cándido Journal of medical case reports BACKGROUND:Adult intestinal intussusception is a rare condition caused by the mechanical disruption of bowel motility. A bezoar is defined as indigestible material inside the gastrointestinal tract that develops into a trapped mass; the most frequent bezoar is a trichobezoar. When a trichobezoar extends into the small intestine it is defined as Rapunzel's syndrome. Literature describing complications related to this pathology remains scarce. CASE PRESENTATION:A 16-year-old Mexican girl presented to our emergency room with acute abdomen and a presumptive diagnosis of intestinal obstruction. Computed tomography was suggestive of intussusception. Surgery confirmed a jejunal-jejunal intussusception with a mass within the gastric cavity extending into her small intestine, corresponding to a trichobezoar. A manual intussusception reduction and a gastrotomy with extraction of the trichobezoar were performed. CONCLUSIONS:We present a case of a jejunum intussusception as a complication of Rapunzel syndrome. Our patient had a favorable outcome after surgical intervention with a manual intussusception reduction, with retrograde displacement of the trichobezoar into the gastric lumen, and a complete extraction through a gastrostomy. Follow-up included psychiatric evaluation. 10.1186/s13256-018-1883-9
    Surgical treatment of gastric outlet obstruction from a large trichobezoar: A case report. Chahine E,Baghdady R,El Kary N,Dirani M,Hayek M,Saikaly E,Chouillard E International journal of surgery case reports INTRODUCTION:Bezoars are concretions of foreign indigestible material accumulating in the gastrointestinal tract leading to intraluminal mass formation that impairs the gastrointestinal motility and can lead to gastric obstruction of the small or the large bowel. There are different types of bezoars, named according to the material they are made of. These include phytobezoar, lactobezoar, pharmacobezoar, trichobezoar, and polybezoar. Trichobezoars (hair ball) are usually located in the stomach but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome). CASE PRESENTATION:Herein, we report a case of a young adult female known to have a long-standing trichophagia who presented with gastric outlet obstruction due to a large trichobezoar. Endoscopy revealed a large and hard gastric trichobezoar not amenable to endoscopic retrieval leading to surgical extraction as a last resort. DISCUSSION:They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. Trichobezoar can be treated either surgically by laparotomy/laparoscopy or by endoscopic intervention. CONCLUSION:Treatment should be coupled to psychiatric evaluation and therapy to prevent recurrence. 10.1016/j.ijscr.2019.04.002
    [Giant Rapunzel syndrome with atypical complication. Report of a case]. Soria Alcívar Miguel,Betancourt Ruiz María,Moyon Gusñay María,Chavez Almeida Josselin,Abarca Rendón Francisco,Robles-Medranda Carlos Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru Rapunzel syndrome is an unusual and rare form of gastric trichobezoar that extends into the small intestine. The formation is due to the continuous ingestion of hair which leads to the impaction of the hair along with mucus and food, but it is rare that gastric perforation occurs. We report the case of a female patient of 16 years of age admitted to our institution with a history of depression and clinical symptoms characterized by nausea, severe epigastralgia and pathological loss of weight. The physical examination showed a tense abdomen with a peritoneal reaction. Contrast-enhanced tomography showed a distended stomach with a heterogeneous content that extended to the duodenum, hydro pneumoperitoneum, Douglas sack bottom liquid, and it was decided to perform an exploratory laparotomy. Showed perforation in the anterior face of the stomach which is infrequent, so we proceeded to the extraction of giant trichobezoar with duodenal extension; Evolving favorably, the patient being referred to outpatient controls with psychiatry; Finally, a high endoscopy was performed at 6 months, which evidenced the scar of the surgical procedure.
    [Gastroduodenal Trichobezoar in school age: Case report]. Castrillón Peña Edna L,Espinosa Moreno Mario F,Barrios Torres Juan C,Forero Niño Edgar E Archivos argentinos de pediatria Bezoar is an accumulation of organic substances in the gastrointestinal tract; trichobezoar refers to the accumulation of hair usually in the stomach and even beyond it (Rapunzel syndrome). The incidence of this condition is extremely rare, 90 % of cases occur in women, and 80 % of these occur in those under 30 years of age and are related to anxiety behaviors and psychiatric disorders. The integral approach in these patients is fundamental, together with the interdisciplinary follow-up, treating the underlying psycho-emotional causes and adequate psychoeducation with the patients and their relatives, in order to reduce the risk of possible recurrences. We present the clinical case of a patient of school age, with a history of physical abuse by her stepfather and subsequent anxious behaviors (trichotillomania and trichophagia). 10.5546/aap.2019.e284
    Fungal Peritonitis with Fungus Balls, a Complication of Trichobezoars and Rapunzel Syndrome. Sotoudeh Ehsan,Hussain Shabbir,Shafaat Omid,Sotoudeh Houman The American journal of case reports BACKGROUND Rapunzel syndrome is a rare condition involving the extension of bezoars from the stomach to the distal gastrointestinal tract. Laparotomy remains the gold standard treatment for this condition because of the size of the bezoars. Although bacterial peritonitis is a known complication of laparotomy in Rapunzel syndrome, very few cases of post-surgical fungal peritonitis have been reported in these patients. CASE REPORT In this case report we present Rapunzel syndrome complicated by post-surgical fungal peritonitis and formation of fungus balls. To our knowledge, fungal peritonitis with fungus balls has never been reported as a Rapunzel syndrome complication.  CONCLUSIONS It is important to cover Candida and other fungi with an antifungal regimen in pediatric patients with Rapunzel syndrome pre- and post-surgery. In addition, prolonged fever and septic symptoms post-surgery warrant a search for peritoneal fungus balls that are not simply responsive to anti-fungal therapy and may necessitate repeat laparotomy. 10.12659/AJCR.915517
    Rapunzel Syndrome: A Rare Case Requiring Surgical Management of Acute Pancreatitis. Winsett Frank,Ting Jose,Harting Matthew T Pancreas 10.1097/MPA.0000000000001301
    Intraluminal bezoar caused obstruction and pancreatitis: A case report. Ebrahimian Saba,Ebrahimian Shadi,Nadri Sedigheh Clinical case reports Acute pancreatitis from bezoar-induced obstruction is rare. We present an uncommon case report of a man with manifestations of Rapunzel syndrome with no known history of mental disorders. Surgical removal of the bezoar through gastrostomy and enterotomy in the absence of a psychiatric undertone will undoubtedly prevent a relapse. 10.1002/ccr3.2145
    [Rapunzel Syndrome Removed with Enteroscopy in a Child]. Chun Sang Woo,Lee Kunsong,Park Youn Joon,Shin Hyun Deok The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi A trichobezoar is a type of bezoar that is composed of hair. In most cases, it is confined to the stomach, but in rare cases, it may extend to the small intestine. This condition is referred to as Rapunzel syndrome. The therapeutic method for bezoar removal depends on its type, location, and size. Generally, the treatment for Rapunzel syndrome involves surgical laparotomy. Endoscopic removal has also been effective in some cases. On the other hand, complications, such as respiratory difficulty and esophageal impaction may be encountered during endoscopic removal. Until now, the successful endoscopic removal of trichobezoars has been limited to the stomach or duodenum. This paper reports the case of a 4-year-old female patient with Rapunzel syndrome whose trichobezoar reached the proximal jejunum. The trichobezoar was removed without complications using an electrosurgical knife and snare through a single-balloon enteroscopy. The trichobezoar can be removed successfully using enteroscopy under general anesthesia without abdominal laparotomy in young children. Therefore, this method of removal can be considered preferentially for children with Rapunzel syndrome. 10.4166/kjg.2019.74.1.42
    Small-Bowel Obstruction Secondary to a Trichobezoar in a Meckel's Diverticulum in a Patient with Rapunzel Syndrome. Otten Maarten J,Charehbili Ayoub,Duinhouwer Lucia E Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 10.1007/s11605-019-04448-x
    The Rapunzel syndrome: a hard-to-swallow tale. Bège Thierry,Desjeux Ariadne,Coquet-Reinier Benjamin,Berdah Stéphane V,Grimaud Jean-Charles,Brunet Christian Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract INTRODUCTION:Rapunzel syndrome is a rare entity comprising of a large gastroduodenal trichobezoar due to trichotillomania. Its treatment is often surgical. CASE REPORT:A 27-year-old patient was investigated after an upper gastro-intestinal tract obstruction. Computed tomography and endoscopy showed a large gastric trichobezoar with a duodenojejunal tail. Conservative treatments failed to remove the bezoar. We performed a short laparotomy which allowed the removal of the bezoar through a longitudinal gastrotomy. Postoperative course was uneventful. 10.1007/s11605-011-1494-x
    A Girl with Abdominal Pain. Mousavi Seyyed Hamid,Nazeri Ali,Behjati Nasrollah,Asadi Karam Alireza,Nejati Seyyed Faraz Archives of Iranian medicine
    Telling the tale of Rapunzel syndrome. Neychev Vladimir,Famiglietti John,Saldinger Pierre F Surgery 10.1016/j.surg.2011.07.074
    Human and Doll's Hair in a Gastric Trichobezoar, Endoscopic Retrieval Hazards. Niţă Andreia F,Hill Chris J,Lindley Richard M,Marven Sean S,Thomson Mike A Journal of pediatric gastroenterology and nutrition Trichobezoars are masses of ingested hair, usually the individual's own hair, that accumulate in the gastrointestinal tract, most commonly in the stomach. When extending into the small intestine, this is termed "Rapunzel syndrome." Removal has traditionally been by laparotomy; however, successful endoscopic removal has also been described. We report the case of a 9-year-old-girl with undiagnosed coeliac disease and Rapunzel syndrome who underwent endoscopic removal of a large trichobezoar, which was followed by unexpected multiple perforations of the small bowel and stomach. Argon plasma coagulation (APC) and snare electrocautery were employed during endoscopy to remove the trichobezoar piecemeal, and approximately 70% was removed without any clear signs of damage to the mucosa. It was discovered subsequently that about 20 of her dolls were found without hair. On investigating the composition of a specific doll hair from the manufacturer, it was discovered that it could be hazardous if burned. It was, therefore, hypothesized that a constellation of factors had conspired to lead to perforation, that is, the potentially hazardous gas produced from the electrical energy applied to the synthetic hair and possible mucosal damage by the physical abrasion of this hair. A review of the literature on endoscopic attempts to remove trichobezoars irrespective of the result reveals a success rate of 30.7%. 10.1097/MPG.0000000000002779
    The Rapunzel syndrome. Report of a case and review of the literature. Duncan N D,Aitken R,Venugopal S,West W,Carpenter R The West Indian medical journal The Rapunzel Syndrome, a rare manifestation of trichobezoar, occurs when bolus gastrointestinal obstruction is produced by an unusual trichobezoar with a long tail that extends to or beyond the ileocaecal valve. A five-year-old Jamaican girl presented with this abnormality and was found at laparotomy also to have an ileo-ileal intussusception. For the Rapunzel Syndrome, we recommend bezoar extraction at laparotomy via multiple enterotomies. In addition, psychiatric evaluation and therapy is essential due to the commonly associated finding of underlying emotional stress.
    The Rapunzel syndrome (trichobezoar) causing atypical intussusception in a child: a case report. Dalshaug G B,Wainer S,Hollaar G L Journal of pediatric surgery The Rapunzel syndrome (trichobezoar) occurs when gastrointestinal obstruction is produced by a rare manifestation of a trichobezoar with a long tail that extends to or beyond the ileocecal valve. A case history of a 7-year-old girl is described. This is the eleventh patient with Rapunzel syndrome reported in the literature. The epidemiology, clinical features, diagnosis, complications, treatment, and literature are reviewed briefly. 10.1016/s0022-3468(99)90504-3
    [Rapunzel syndrome: case report and literature review]. Curioso Vilchez Walter H,Rivera Vega Juan,Curioso Abriojo Walter I Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru The Rapunzel syndrome is a rare form of gastric trichobezoar crossing the pylorus and extending throughout the bowel. The case of a 22-year-old Peruvian woman is reported. This is the thirteenth patient with Rapunzel syndrome reported in the literature. The epidemiology, clinical manifestations, diagnosis and treatment are briefly reviewed.
    Rapunzel syndrome: a diagnosis overlooked. Mathai John,Chacko Jacob,Kumar T Sathish,Scott Julius Xavier,Agarwal Indira,Varkki Sneha Acta paediatrica (Oslo, Norway : 1992) UNLABELLED:We report two children who presented with a painless abdominal mass masquerading as a splenic enlargement. The paucity of symptoms resulted in delayed diagnosis. At laparotomy the trichobezoars were found to have a tail extending into the small intestine. CONCLUSION:This condition eludes diagnosis unless sought for particularly in the paediatric age group. Hence we present our experience of two consecutive cases of paediatric Rapunzel syndrome, along with the relevant literature and in retrospect, how an early diagnosis could have been made. 10.1111/j.1651-2227.2007.00012.x
    Rapunzel syndrome. Al-Wadan Ali H,Al-Absi Mohamed,Al-Saadi Azan S,Abdoulgafour Mohamed Saudi medical journal An 18-year-old single female patient, presented with non specific gastrointestinal symptoms of anorexia, abdominal pain, and change in bowel habit. Clinically she was anemic, cachectic, and depressed. Abdominal examination revealed mobile epigastric mass. The scalp alopecia and endoscopy coupled by computed tomography scan, confirmed the diagnoses of trichobezoar, but it was not diagnosed as Rapunzel syndrome except after laparotomy, gastrotomy, and enterotomy. There are less than 16 cases of Rapunzel syndrome described worldwide, and this is the first case to be described in the middle east.
    [Gastric perforation due to trichobezoar in an adult (Rapunzel syndrome)]. Pérez Esteban,Sántana José Ramón,García Gabriel,Mesa José,Hernández Juan Ramón,Betancort Néstor,Núñez Valentín Cirugia espanola Rapunzel syndrome, or trichobezoar, is an uncommon entity and secondary gastric perforation is exceptional. We found no adult cases reported in the literature. Our patient is a teenager with clinical symptoms of epigastric mass and acute abdomen. Radiological study showed pneumoperitoneum and intragastric mass. Personal history revealed depressive syndrome and anxiety. Urgent laparotomy confirmed the diagnosis of gastric perforation due to a trichobezoar completely moulding the gastric chamber. The diagnosis was suspected on the basis of radiologic images but laparotomy was required to confirm it. 10.1016/s0009-739x(05)70931-3
    Rapunzel syndrome: a case report and review. Western Catherine,Bokhari S,Gould S Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract We report a 14-year-old girl who presented with epigastric pain, vomiting, and an upper abdominal mass. A diagnosis of trichobezoar was made on ultrasound and she went on to have a laparotomy, where a large trichobezoar was extracted with a tail that extended into the small intestine. 10.1007/s11605-007-0408-4
    Rapunzel syndrome reviewed and redefined. Naik Saleem,Gupta Vivek,Naik Swati,Rangole Ashwin,Chaudhary Ashok K,Jain Prashant,Sharma Ashok K Digestive surgery Rapunzel syndrome is a rare presentation of a trichobezoar, with 24 cases having been reported in literature so far. This syndrome has been reported in 23 female and 1 male patient with a mean age of 10.8 years. The patients commonly present with abdominal pain, nausea, vomiting and signs of obstruction. The distal end of the bezoar may be in the jejunum, ileum or the colon. We evaluate the various cases reported and discuss the various modes of presentation of this uncommon syndrome, and also present a series of 3 cases, all females, aged 16, 18 and 21 years, and had a trichobezoar in the stomach with a tail extending into the ileum. 10.1159/000102098
    Rapunzel syndrome in a pediatric patient: a case report. Middleton Elizabeth,Macksey Lynn Fitzgerald,Phillips J Duncan AANA journal This case report describes a 2.5-year-old girl who was hospitalized with complaints of abdominal pain and vomiting for 2 days. Abdominal ultrasound revealed small bowel-to-small bowel intussusception. Diagnostic laparoscopic-assisted exploration of the abdomen revealed 4 separate intestinal intussusceptions along with multiple dark intraluminal masses within the small intestine. Laparoscopic reduction of the intussusceptions was unsuccessful. Laparotomy allowed palpation of the entire small intestine with extraction of the masses, which were found to be human hair (trichobezoars). The intussusceptions were reduced, and the multiple masses were removed through a single enterotomy. The child recovered following surgery and was discharged home to her family. The surgeon counseled the parents before discharging the patient and recommended follow-up counseling for their child. The parents were given information about trichophagia and strategies to reduce the behavior in their child. A comprehensive literature review revealed this to be the youngest reported case of intussusception and Rapunzel syndrome due to trichobezoars.
    The Rapunzel syndrome: is it an Asian problem? (case report and review of literature). Mehta Puja,Bhutiani Rajinder European journal of gastroenterology & hepatology Trichobezoars are intraluminal accretions of ingested hair. The Rapunzel syndrome is a rare form of gastric trichobezoar, with extension into the small bowel, and may be complicated by obstruction, perforation or peritonitis. The majority of reported cases are from Asian countries. We describe the second case from England who, like the earlier report, is also a 14-year old Asian girl who presented with small bowel obstruction. The pathology was missed 2 years previously when she presented with slim stature, iron-deficiency anaemia and frontal alopecia. This report highlights the need for a higher index of suspicion, particularly in Asian girls to avoid missing the diagnosis and early elective intervention. 10.1097/MEG.0b013e3283140ed2
    Rapunzel syndrome and gastric perforation. Tayyem Raed,Ilyas Imran,Smith Iain,Pickford Ian Annals of the Royal College of Surgeons of England Rapunzel syndrome complicated with gastric perforation is a very rare presentation of trichobezoar. Trichobezoar is an uncommon condition affecting predominantly females. It has non-specific clinical presentation, a wide range of complications, and, if not treated appropriately, carries significant mortality. Traditional treatment of trichobezoar is surgical, though, attempts have been made to excise endoscopically, dissolve chemically or fragment using extracorporeal shock waves. We report a case of a very large trichobezoar occupying most of the stomach and duodenum complicated with gastric perforation, and summarise the literature regarding trichobezoar aetiology, diagnostic difficulties, and management. 10.1308/147870810X476700
    Treatment of recurrent Rapunzel syndrome and trichotillomania: case report and literature review. Jones Guy C,Coutinho Karl,Anjaria Devashish,Hussain Najeeb,Dholakia Rashesh Psychosomatics BACKGROUND:Trichotillomania (obsession with one's hair) was first described in the literature over 100 years ago and was recognized by the American Psychiatric Association as a distinct disorder in 1987. OBJECTIVE:The authors discuss a rare presentation of a case of recurrent Rapunzel syndrome in a 37-year-old woman. METHOD:The authors present a biopsychosocial treatment plan for a therapeutic approach. RESULTS:This patient was unique for her relatively advanced age at onset, the recurrent nature, association with pancreatitis, and the consumption of artificial hair extensions, rather than her own hair. This patient presented with small-bowel obstruction requiring laparotomy. After surgery, she was evaluated by the psychiatric service; after discharge, she removed her hair extensions, continued to take her prescribed medication, attended a psychiatric program, and was monitored by family and friends. CONCLUSION:There are no definitive guidelines for treating trichotillomania. In this case, quetiapine, hair-extension removal, family involvement, and regular follow-up helped with the initial cessation of her hair consumption. Antidepressant treatment helped control the obsession while behavioral therapy and family involvement provided the means for habit-reversal training. 10.1176/appi.psy.51.5.443
    Rapunzel syndrome: a comprehensive review of an unusual case of trichobezoar. Gonuguntla Veena,Joshi Divya-Devi Clinical medicine & research An unusual form of bezoar extending from the stomach to the small intestine or beyond has been described as Rapunzel syndrome. Bezoars are concretions in the gastrointestinal tract that increase in size by continuous accumulation of non-absorbable food or fibers. Most bezoars in children are trichobezoars from swallowed hair from the head, dolls, or brushes. Trichobezoars typically cause abdominal pain and nausea, but can also present as an asymptomatic abdominal mass, progressing to abdominal obstruction and perforation. Trichobezoar with Rapunzel syndrome is an uncommon diagnosis in children with less than 40 cases reported. It is predominantly found in emotionally disturbed or mentally retarded youngsters. We present the youngest case of Rapunzel syndrome in the United States, a 5-year-old girl with mental retardation who presented with abdominal pain, vomiting and a non-tender abdominal mass. 10.3121/cmr.2009.822
    The surgical management of Rapunzel syndrome: a case series and literature review. Fallon Sara C,Slater Bethany J,Larimer Emily L,Brandt Mary L,Lopez Monica E Journal of pediatric surgery BACKGROUND/PURPOSE:The surgical removal of a trichobezoar is the rare end complication of the psychiatric disorders trichotillomania and trichophagia. The more severe form of the disease is termed Rapunzel syndrome, where the bezoar extends from the gastric body beyond the pylorus into the duodenum. Traditional therapy has included endoscopy, often with subsequent laparotomy, and associated psychiatric intervention. We present the largest and most recent series of patients with trichobezoars managed in a single institution. METHODS:A retrospective review of all cases of trichobezoar at our institution from 2003 to 2011 was performed. Demographic data, presenting complaints, imaging, surgical treatment, and subsequent management were collected. RESULTS:All 7 patients were female, ages 5 to 23 years (mean, 11.5 years). Although multiple imaging modalities were necessary for preoperative diagnosis, most patients were accurately diagnosed without endoscopic evaluation (85%). All patients required an exploratory laparotomy for definitive treatment. At laparotomy, 5 patients were found to have postpyloric extension of the trichobezoar (71%). One of 7 patients had a wound infection postoperatively. There were no other surgical complications or recurrences requiring further exploration. CONCLUSIONS:Our series of trichobezoar patients appear to have a high rate of Rapunzel syndrome, and perhaps postpyloric extension should be considered the rule rather than the exception. Our series demonstrates that diagnosis can be established with a thorough history combined with radiography, and treatment should be a combination of laparoscopy and/or laparotomy with psychiatric consultation. 10.1016/j.jpedsurg.2012.07.046
    Rapunzel syndrome (gastric trichobezoar), a rare presentation with generalised oedema: case report and review of the literature. Nour Islam,Abd Alatef Mona,Megahed Ahmed,Yahia Sohier,Wahba Yahya,Shabaan Abd Elazeez Paediatrics and international child health Rapunzel syndrome is a rare form of gastric trichobezoar. A 4-year-old girl presented with generalised oedema and an epigastric mass. Her family was of a relatively low socio-economic background. There was microcytic hypochromic anaemia, hypoalbuminaemia and an elevated α1-antitrypsin clearance. Abdominal ultrasound and non-contrast computed tomography demonstrated a heterogeneous mass related to the stomach. Upper gastro-intestinal tract endoscopy failed to remove it. Surgical laparotomy was undertaken through a single anterior gastrotomy incision and a large mass was extracted which was a cast of the duodenum and stomach and had a tail of approximately 60 cm in length which extended to the jejunum. Low socio-economic status, child neglect and pica are risk factors for trichobezoars. Surgical laparotomy is the optimal treatment of large bezoars. 10.1080/20469047.2017.1389809
    Rapunzel syndrome in adult with mysterious presentation: a rare case report with literature review. Kumar Navin,Huda Farhanul,Gupta Rohit,Payal Y S,Kumar Utkarsh,Mallik Dhiraj Tropical doctor Bezoars are indigestible foreign material in the gastrointestinal tract (GIT). A phytobezoar is a mass of plant material, while a trichobezoar consists of matted hair. This is found most commonly in the stomach in children who chew their long hair. When a gastric trichobezoar extends to the duodenum or jejunum, this is known as Rapunzel syndrome (RS), after a famous Brothers' Grimm fairy tale. Our patient presented with haematemesis, localised peritonitis, a palpable epigastric mass, coagulopathy, severe anaemia and deranged liver function tests. An abdominal computed tomography scan was suggestive of a bezoar; gastroduodenoscopy confirmed the diagnosis. Treatment of trichobezoars normally involve endoscopic removal or gastrotomy and psychiatric intervention. They may also cause haematemesis, gastric outlet obstruction, gastric ulceration and perforation, multiple jejuno-jejunal intussusception, acute pancreatitis and cholestatic jaundice. Trichobezoar was first reported in the 18th century by Baudamant in a 16-year-old boy. RS was first described in 1968. 10.1177/0049475519826477
    [Intestinal trichobezoar: differential diagnosis in children with an abdominal mass]. Azuara-Fernández H M,Azuara-Gutiérrez H,Hernández-Márquez N,Revilla-Cepeda E,Aportela A,Andrade-Sepúlveda V R Boletin medico del Hospital Infantil de Mexico Due to it's rare appearance, the intestinal trichobezoar is usually not considered as a differential diagnosis of abdominal masses seen in children. A case of a 10 year old girl with a five month evolved inferior hemi-abdominal mass is cited. The girl appeared severely ill and within 24 hours of her physical examination, showed signs and symptoms of an intestinal obstruction. She was admitted to surgery with the diagnosis of a non Hodgkin lymphoma. Due to its' presentation, we may have even supposed it to be a case of Rapunzel syndrome which grew within the intestine causing obstruction or which may have initially grown in the terminal ileum. The medical literature is reviewed.
    Management of trichobezoar: case report and literature review. Gorter R R,Kneepkens C M F,Mattens E C J L,Aronson D C,Heij H A Pediatric surgery international Trichobezoars (hair ball) are usually located in the stomach, but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome). They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. In the literature several treatment options are proposed, including removal by conventional laparotomy, laparoscopy and endoscopy. We present our experience with four patients and provide a review of the recent literature. According to our experience and in line with the published results, conventional laparotomy is still the treatment of choice. In addition, psychiatric consultation is necessary to prevent relapses. 10.1007/s00383-010-2570-0
    The Rapunzel syndrome: a case report and review of the literature. Balik E,Ulman I,Taneli C,Demircan M European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie The Rapunzel syndrome, found characteristically in girls with varying gastrointestinal symptoms, is a rare form of gastric trichobezoar extending throughout the bowel. The previously reported cases have different clinical and pathological features affecting the mortality. We describe a new case preoperatively diagnosed with none of the complications previously reported. 10.1055/s-2008-1063536
    [Rapunzel syndrome as a cause ofobstruction and intestinal perforation]. Rojas Patricia Guzmán,Paredes Eduar Bravo,Reto Catherina Pichilingue Acta gastroenterologica Latinoamericana The following is a case report involving a 16 year old femalewith trichotillomania as an antecedent. This patient presentedto the Emergency Room with a chief complaint of earlysatiety and persistent abdominal pain for the past 3 months.However, recently her abdominal pain has worsened and itis now complicated by nausea and vomiting. The physicalexam was notable for epigastric pain on deep palpation. Thebiochemical analysis and abdominal ultrasound were otherwiseunremarkable. An esophagogastroduodenoscopy wassubsequently performed where a trichobezoar was discovered.It extended from the gastric fundus to the third portion ofthe duodenum. A surgical extraction of the trichobezoar wasthen performed. The trichobezoar was found to be 130 cmin length and 8 cm wide at its most cephalad aspect. It isimportant to note that they also found five mall perforationsthroughout the duodenum and jejunum. The patient wasdischarged with outpatient follow up with psychiatry. In thisreport we describe the case of a patient with Rapunzel syndromethat was complicated by small bowel perforation andwe provide a review of the salient literature concerning thissyndrome and its associated complications.
    Trichotillomania, recurrent trichobezoar and Rapunzel syndrome: case report and literature review. Morales-Fuentes Bulmaro,Camacho-Maya Ulises,Coll-Clemente Fanny Leslie,Vázquez-Minero Juan Carlos Cirugia y cirujanos BACKGROUND:Bezoar is a conglomeration of foreign material in the intestinal tract. Trichobezoar (accumulation of hair in the gastric chamber, secondary to impulsive pulling and intake) and Rapunzel syndrome (accumulation of hair in the small intestine) usually occur in children and adolescents with trichotillomania (TTM) and trichophagia history. CLINICAL CASE:We present the case of a 22-year-old female who arrived for consultation. The patient had a 10-month history of intermittent abdominal pain, gastric fullness, nausea, occasional vomiting and weight loss. In addition, she had a history of TTM, trichophagia and previous gastrotomy at 16 years of age. Laboratory tests revealed hypochromic microcytic anemia. Ultrasonographic study demonstrated intense sonic shadowing posterior to the gastric area. After performing gastrotomy, the specimen was extracted and consisted of hair that occupied the entire length of the gastric chamber and part of the small intestine. CONCLUSIONS:TTM is characterized by recurrent and impulsive pulling of one's hair for pleasure, gratification, or relief of tension. Children and women <30 years of age are the groups who most frequently suffer from this type of disorder. Hair intake sensation was a cause for presentation of the disease. Data recollection in our environment may provide information for the determination of new information regarding the presence of this condition.
    Recurrent Rapunzel syndrome - A rare tale of a hairy tail. Nettikadan Antony,Ravi M J,Shivaprasad M International journal of surgery case reports INTRODUCTION:Rapunzel syndrome is a rare condition predominantly found in trichophagic females that occurs when gastric trichobezoar extends beyond the pylorus and into duodenum, jejunum, ileum or even to colon. There are only five cases reported in literature. This case report has been reported in line with the SCARE criteria. PRESENTATION OF CASE:A 19 year old female, with a history of trichotillomania with trichophagia, who presented with epigastric pain and vomiting for 12 months. She underwent laparotomy ten years back to extract a trichobezoar, which was diagnosed to be Rapunzel syndrome and lack of follow-up resulted in recurrence. Further examination and imaging showed a large trichobezoar extending into small intestine. She underwent gastrotomy and entrerotomy and extraction of hairball. DISCUSSION:In a trichophagic female with abdominal pain, nausea and vomiting, and abdominal mass, diagnosis is done by ultrasound, CT scan and upper gastrointestinal endoscopy. Small trichobezoars can be removed endoscopically. Large (>20 cms)acutely symptomatic trichobezoars, especially when accompanied by Rapunzel syndrome, must be removed surgically by gastrotomy and enterotomy is required if impacted extension is present. Long-term surgical and psychiatric follow-up with psychotherapy and cognitive behavioural therapy along with selective serotonin reuptake inhibitors are critical to prevent recurrences. CONCLUSION:Although Rapunzel syndrome is an extremely rare disease, it should be considered when diagnosing young women, especially those with a history of trichophagia or trichotillomania. After the surgical removal of trichobezoars by laparotomy, long-term follow-up combined with psychiatric consultation is recommended to prevent recurrences. 10.1016/j.ijscr.2018.03.017
    A case of rapunzel syndrome. Kim Joon Sung,Nam Chang Woo Pediatric gastroenterology, hepatology & nutrition Rapunzel syndrome refers to a very rare condition in which swallowed hair forms a gastric trichobezoar that has a long tail extending into the small bowel. We describe a case of Rapunzel syndrome in an 8-year-old girl who presented with abdominal mass, epigastric pain and vomiting. Abdominal computed tomography scan showed a markedly dilated stomach filled with coarse heterogeneous materials. Upper gastrointestinal endoscopy revealed a huge hairy ball with a tail extending through the pylorus. We performed a surgical laparotomy and successfully removed a huge trichobezoar with a long tail extending into the middle portion of jejunum. Psychiatric consultation with review showed her past history of trichotillomania and trichophagia 4 years ago. But her parents denied further psychiatric therapy and she was lost to the follow-up. Rapunzel syndrome should be included in the differential diagnosis in children with chronic abdominal pain and trichophagia. 10.5223/pghn.2013.16.2.127
    Giant gastric trichobezoar in a young female with Rapunzel syndrome: case report. Hamid Mohamed,Chaoui Youssef,Mountasser Mohamed,Sabbah Farid,Raiss Mohammed,Hrora Abdelmalek,Alaoui Mouna,Ahallat Mohammed,Chaouch Safaa,Ouazzani Houria The Pan African medical journal Rapunzel syndrome is an extremely rare complication of a gastric trichobezoar in. We report here the unusual case of a case of a 16 years old girl presented with severe abdominal pain and vomiting. Clinical examination revealed a malnourished girl, with presence of a mobile and sensitive abdominal mass of 20x15 cm witch filled the upper quadrant. An abdominal computed tomography scan showed a heterogeneous mass occupying the whole stomach cavity with extension into the third portion of the duodenum. A diagnostic of giant trichobezoar is suspected after further questioning reveling a trichotillomania, trichophagia and onychophagia. The removal of the trichobezoar endoscopically failed and it was possible to pull only few fibers of hair to comfort the diagnostic. She was subjected to an exploratory laparotomy. An antral gastrostomy were performed and a 25x10x7 cm trichobezoar was extracted. The patient had an uneventful postoperative outcome and was derived to psychiatry. Rapunzel syndrome is an uncommon trichobezoar, it's commonly found in young females usually with an underlying psychiatric disorder. Management requires gastrotomy. A psychiatric assessment and a long-term follow-up are advocated as a regular part of treatment to prevent recurrence. 10.11604/pamj.2017.27.252.9110