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bezoars are collections of indigestible material that accumulate in the gi tract and are most often located in the stomach . trichobezoars are often associated with psychiatric illness like trichotillomania and trichophagia usually occurs in young and adolescent females .
gastric trichobezoar ( gt ) is the most common variety of bezoar found in the stomach . on the basis of their contents
, bezoars are classified into phytobezoars ( composed of non - digestible food materials such as seeds and pits ) , trichobezoars ( composed of hair ) , lactobezoars ( composed of lactose ) , and pharmacobezoars ( composed of medications ) .
the most common complications reported over the years , include gastric mucosal erosion , ulceration , and perforation of the stomach or the small intestine , gastric outlet obstruction , intussusception , obstructive jaundice , protein - losing enteropathy , pancreatitis and death .
usually trichobezoar is confined to the stomach , but it can migrate through the pylorus into the jejunum , ileum or even the colon .
rapunzel syndrome was first reported in the west indies by duncan et al . in 1994 .
trichotillomania is a dsm - iv - tr 312.39 psychiatric classification of impulse control disorders .
50% of all bezoars are gastric with an incidence of 0.4% to 1% , however , this is most likely an underestimation .
a 30-year - old woman , mother of two , reported to the emergency department with the complaints of pain in middle abdomen , not passing flatus or motion ( obstipation ) and abdominal distension for the past 5 days .
after initial resuscitation , an erect abdominal radiograph was taken , which revealed gas under right side of diaphragm and an unusual shadow in the left hypochondrium in the region of the stomach ( figure 1 ) .
an emergency exploratory laparotomy was performed and around two liters of pyoperitoneum was removed . on exploration ,
a 22 cm perforation was identified in the anterior wall of the prepyloric region of stomach .
a large mass could also be felt in the stomach extending from fundus to the pylorus .
the mass was foul smelling and contained densely wound bunch of hair , threads and bits of plastic .
the gastroenterotomy was repaired primarily in single layer with non - absorbable suture and perforation with graham s omental patch .
the patient had a scarred area of alopecia , which was supported by the history of eating hair for the past 4 years ( figure 3 ) .
shows abdominal x - ray ( ap view ) suggestive of gas under diaphragm with filling defect . shows intraoperative findings , visible large hairs through perforation .
trichobezoars is usually seen in adolescent girls , often with an underlying psychiatric or social problem .
once the bezoar extends from the stomach into the jejunum or further on , it is referred to as  rapunzel syndrome ,  which was first described in 1968 by vaughan jr .
this increases the risk of severe complications , such as gastric mucosal erosion , ulceration and even perforation of the stomach or the small intestine .
apart from intussusception , other complications reported in unrecognized trichobezoars are obstructive jaundice , protein - losing enteropathy , pancreatitis , and even death .
perforation is a known complication of trichobezoars of either the stomach or the intestine , which should be vigilantly looked for and its complications . as the size of the trichobezoar increases , the blood supply to the mucosa of the stomach and part of the intestine
laparotomy is considered as the treatment of choice in view of high success rate , relatively low complication rate , and low complexity .
in addition , the entire gastrointestinal tract can be evaluated for satellites in a short period of time .
hair strands because of their slippery surface , escape peristaltic propulsion and are retained in the folds of the gastric mucosa .
the hairball lies dormant and the trichobezoar continues to grow in size and weight due to the incessant ingestion of hair .
ultimately , the gt attains the shape of the stomach , usually as a single solid mass .
the most common symptoms are epigastric pain ( 70.2% ) , epigastric mass ( 70% ) , nausea and vomiting ( 64% ) , hematemesis ( 61% ) , weight loss ( 38% ) , and diarrhea and constipation ( 32% ) .
a preoperative diagnosis of trichobezoar may be suggested in a patient presenting with severe halitosis , patchy alopecia , a previous history of trichotillomania and trichophagia .
other associated complications of gt are malabsorption related , which include protein - losing enteropathy , iron deficiency anemia , and megaloblastic anemia .
stated the most common complication is either perforation of the stomach or intestine ( occurring in 10.1% of cases ) , followed by intussusception ( 1.85% ) , pancreatitis ( 0.92% ) and cholangitis ( 0.92% ) .
the management of trichobezoars is removal of mass , presence of complications , and prevention of recurrence .
smaller size of trichobezoars can be removed endoscopically by the use of basket or direct suction , but in cases with a larger size it is difficult and reports are scarce . in this case , we opted for laparotomy as we did not know what we are dealing with .
though laparoscopy is superior to laparotomy in view of cosmetic results , less postoperative complication and less hospital stay , but in the laparotomy careful examination of the entire gastrointestinal tract is easier to prevent secondary intestinal obstruction due to migration of residual bezoars .
laparotomy , the gold standard , is the most effective and hence the most common technique in the medical literature .
few patients have seemed to benefit from fluoxetine or other serotonin reuptake inhibitors , although these results are not consistently reproducible in all patients . to avoid recurrence ,
a diagnosis of trichobezoar should be considered in patients with epigastric lump with coexisting psychiatric disorder .
after treatment of trichobezoar , a psychiatric evaluation of the patient should be considered to get to the root cause of the problem .
trichobezoars are impactions of swallowed hairs in the stomach and occasionally in the intestine . 
 they occur in emotionally disturbed , depressed , or mentally retarded patients who have trichotillomania and trichophagia . 
 trichobezoars are usually diagnosed on ct scan or upper gi endoscopy . 
 they can give rise to complications like gastroduodenal ulceration , haemorrhage , perforation , peritonitis , or obstruction , with a high rate of mortality . 
 the treatment is endoscopic , laparoscopic , or surgical removal and usually followed by psychiatric opinion . 
 herein , we report a case of gastric trichobezoar presenting as gastric perforation in a patient of trichotillomania and trichophagia that was accidentally found on laparotomy . as the patient was in shock on admission , relevant history of trichophagia 
 could not be elicited . 
 henceforth , she was operated for perforation peritonitis . 
 trichobezoar was discovered intraoperatively and removed . 
 the perforation was repaired with graham s omental patch . 
 postoperatively , history of trichophagia was corroborated with scarring alopecia of scalp . 
 trichobezoars is usually seen in adolescent girls , often with an underlying psychiatric or social problem . 
 laparotomy is the gold standard treatment . 
 surgical treatment should be followed by behavioral and psychiatric treatment . 
 the patient should be vigilantly monitored for this impulsive disorder , as recurrences are common .