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composed of hair.
Phytobezoars (most common):
composed of vegetable matter
composed of ingested medications.

Occurred in patient with Trichotillomania and Trichophagia
Retained hairs between the gastric folds
Denatured by gastric acid
Combines with food to form an enmeshed mass
Once formed, bezoars grow by the continuing ingestion of
food rich in cellulose and other indigestible materials, matted
together by protein, mucus, and pectin.

Most cases : the trichobezoar
is conned within the
Trichobezoar extends
through the pylorus into
jejunum, ileum or even colon
=> Rapunzel syndrome

Trichobezoar: Epidemiology
Typically seen in women in their 20s
Often associated with psychiatric disorders
Rapunzel syndrome: almost exclusively in young girls

Clinical Manisfication
Asymptomatic for many years and insidious onset
Most Common

early satiety
weight loss

PE: occasional abdominal mass or halitosis

Gastric mucosal erosion, ulceration
Perforation of the stomach or the small intestine.
Other possible complication in literature:
obstructive jaundice
protein-losing enteropathy, pancreatitis

Bezoar: Image
Phytobezoars : impervious to barium
Trichobezoars: absorb barium

Trichobezoar: Sonography
Sonography: intraluminal mass
with a hyperechoic arclike
surface and a marked acoustic
shadow is suggestive of a
Marked acoustic shadowing
behind the echogenic band
different from dirty
shadowing generated by
ingested gas and food within
the stomach.
Pediatric Radiology
August 1990, Volume 20, Issue 7, pp 526-527

Trichobezoar: CT
Multiple compressed
concentric ring appearance
with entrapped air and
Mottled gas pattern

Differential diagnosis in Image

Lobulated, villous adenoma of gastroduodenal region
Soft tissue tumour such as a leiomyosarcoma projecting into
the lumen in the gastro-duodenal region
Discrete boarder is important

Bezoar: Diagnosis
Upper gastrointestinal endoscopy is required to establish the
diagnosis of a gastric bezoar and to obtain samples to
determine its composition.
Endoscopically, a gastric bezoar has the appearance of a dark
brown, green, or black ball of amorphous material in the
fundus or antrum of the stomach

Pediatr Surg Int (2010) 26:457463

Between 1990 and 2008, four patients have been treated for
trichobezoar in Emma Childrens Hospital AMC and VU
University, Netherland

Bezoar: Management
Chemical dissolution
Coca-Cola (3000 mL over a 12-hour period)
Acetylcysteine (15 mL of acetylcysteine in 50 mL of water, twice daily)

Endoscopic removal
Adjuvant prokinetics:


Trichobezoar :Management
Enzymatic degradation and pharmacotherapyineffective
Minimally invasive surgery?
Endoscopy with mechanical and laser fragmentation?
Endoscopic fragmentation is generally impossible due to the
hard consistency and high density of the hair conglomerate
(Gorter et al. reviewed 40 reported trichobezoar cases in which endoscopic removal was attempted and found that
elimination was successful in only 2 of these cases )

Most trichobezoars are removed via laparotomy or laparoscopic


Endoscopic removal
Fragmentation is usually impossible because of size, density
and hardness
Careful examination of the intestine for satellites, however,
cannot be done with endoscopy, let alone that removal of
those fragments is possible

Endoscopic fragmentation
Endoscopic fragmentation with
an argon plasma coagulation
device and polypectomy snare,
in addition to dissolution with
Coca-Cola, failed to remove the
trichobezoar. The tangled
conglomerate of hair was
successfully fragmented using
several types of electrosurgical
Intern Med. 2014;53(11):1099-105. Epub 2014 Jun 1., 10y girl

Careful examination of the entire digestive system (intestine and
stomach) is necessary in order to prevent secondary intestinal
obstruction due to satellites
The risk of spilling contaminated hair fragments into the
abdominal cavity makes the laparoscopic approach less attractive.
Successful laparoscopic removal requires nicantly longer
operation time as compared to conventional laparotomy, mostly
due to the complexity of the operation.

Near 100% successful rate
Allow carefully examine the entire gastrointestinal tract for
satellites in a short period of time
Only valid choice in Rapunzel syndrome:
endoscopic removal should not even be tried as the tail usually
reaches into the jejunum and manipulation carries the risk of
parts breaking off.
perforation of the intestine during removal, paralytic ileus,

Perverted craving for substances unfit to be used as food
Etymology: the medieval Latin name for the bird called the
magpie, who, it is claimed, has a penchant for eating almost
Pediatrics Vol. 44 No. 4 October 1, 1969 pp. 548
The prevalence of pica is unclear

scientific name: Pica pica

Pica: Diagnostic Criteria

Persistent eating of nonnutritive, nonfood substances over a period of
at least 1 month.
The eating of nonnutritive, nonfood substances is inappropriate to
the developmental level of the individual.
The eating behavior is not part of a culturally supported or socially
normative practice.
If the eating behavior occurs in the context of another mental
disorder (e.g., intellectual disability [intellectual developmental
disorder], autism spectrum disorder, schizophrenia) or medical
condition (including pregnancy), it is sufficiently severe to warrant
additional clinical attention.

A diagnosis of pica may be assigned in the presence of any
other feeding and eating disorder
Pica comes to clinical attention following general medical
complications (e.g., mechanical bowel problems; in testinal
obstruction, such as that resulting from a bezoar; intestinal
perforation; infections such as toxoplasmosis and toxocariasis
as a result of in gesting feces or dirt; poisoning, such as by
ingestion of lead-based paint).

Pica: Development and Course

Childhood onset is most commonly
Pica can occur in otherwise normally developing children
(in adults, more likely to occur in the context of intellectual disability or other mental disorders)

Neglect, lack of supervision, and developmental delay can

increase the risk for this condition.

Pica: Differential Diagnosis

KleineLevin syndrome
Autism spectrum disorder
Anorexia nervosa: as a means of attempting to control appetite
Factitious disorder: intentionally ingest foreign objects as part
of the pattern of falsification

Back to our patient

Pica (trichophagia) with trichotillomania
Futher psychiatric follow up as outpatient to prevent relapse
Suggest psychiatric consultation to her classmate

Take home message

Trichobezoar should be considered in young females
presenting with non-specic abdominal complaints.
Endoscopy can be used as a diagnostic modality for these
patients as it can differentiate trichobezoar from other types of
bezoars, which can be removed safely with endoscopy
Psychiatric consultation is necessary in order to prevent

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