What Are Trichobezoars and How Can They Be Treated?

What you need to know

• A trichobezoar is a rare condition where a ball of hair forms in the stomach, usually due to a person habitually pulling out and eating their own hair
• Trichobezoars can grow quite large before causing noticeable symptoms like abdominal pain, vomiting, and a palpable mass in the upper abdomen
• Large trichobezoars typically require surgical removal, as they are too dense and compacted for endoscopic removal
• The underlying hair-pulling and eating behaviors (trichotillomania and trichophagia) require psychological treatment to prevent recurrence

What is a trichobezoar?

A trichobezoar is an accumulation of hair in the digestive tract, typically in the stomach. The word “trichobezoar” comes from the Greek words “trich” meaning hair and “bezoar” referring to a mass trapped in the gastrointestinal system. While this may sound like a strange and rare occurrence, it’s an important condition for both medical professionals and the general public to be aware of, especially in relation to certain psychological disorders.

Trichobezoars form when a person repeatedly ingests hair over an extended period. This behavior, known as trichophagia, is often associated with trichotillomania - a mental health condition characterized by an irresistible urge to pull out one’s hair. When hair is swallowed, it does not break down in the digestive system like food does. Instead, it can accumulate in the stomach, gradually forming a large, matted ball.

How common are trichobezoars?

Trichobezoars are quite rare. It’s estimated that only about 1% of people with severe trichotillomania will develop a trichobezoar that requires surgical intervention. To put this in perspective, trichotillomania itself has a lifetime prevalence of 0.6-2.4% in the general population, and only 5-18% of those who pull their hair also eat it. This means that trichobezoars are a rare complication of an already uncommon behavior.

What are the symptoms of a trichobezoar?

One of the most challenging aspects of trichobezoars is that they can grow quite large before causing noticeable symptoms. This is because the stomach can expand to accommodate the growing mass. When symptoms do appear, they may include:

1. Abdominal pain
2. Nausea and vomiting
3. A noticeable lump in the upper abdomen
4. Changes in bowel movements
5. Weight loss
6. Fatigue

In the case study presented in the research paper, the child had been experiencing vomiting and abdominal pain for four days. Upon examination, a large, hard mass about 20 cm in diameter could be felt in the upper abdomen. This illustrates how substantial a trichobezoar can become before it’s detected.

How are trichobezoars diagnosed?

Diagnosing a trichobezoar typically involves a combination of clinical examination and imaging studies. The process might include:

1. Physical examination: A doctor may be able to feel a firm, non-tender mass in the upper abdomen.

2. Medical history: A history of trichotillomania or trichophagia can be a significant clue.

3. Blood tests: These might show anemia or other nutritional deficiencies due to the trichobezoar interfering with digestion and nutrient absorption.

4. Imaging studies:

   • Ultrasound can often detect the mass in the stomach.
   • X-rays, particularly with contrast, can show the outline of the trichobezoar.
   • CT scans are highly effective, detecting up to 97% of trichobezoars, but they involve radiation exposure and are usually avoided in children if possible.

In the case study, the diagnosis was made using ultrasound and X-rays with contrast, avoiding the need for a CT scan.

What is Rapunzel syndrome?

In some cases, a trichobezoar can develop an unusual and potentially dangerous feature known as Rapunzel syndrome. This occurs when the trichobezoar extends from the stomach into the small intestine, forming a long “tail.”

The name comes from the fairy tale character Rapunzel, known for her extremely long hair. In medical terms, Rapunzel syndrome refers to a trichobezoar with a tail extending at least to the jejunum (the middle section of the small intestine).

This tail can cause additional complications, including intestinal obstruction or perforation. In the case study, the trichobezoar had a tail about 60 cm long extending into the small intestine, classifying it as Rapunzel syndrome.

How are trichobezoars treated?

The treatment of trichobezoars typically involves two main components: removal of the hair mass and addressing the underlying psychological condition.

1. Removal of the trichobezoar:

   • Small trichobezoars might be removed endoscopically, using tools inserted through the mouth and esophagus.
   • Larger trichobezoars, like the one in the case study, usually require surgical removal. This involves making an incision in the abdomen (laparotomy) and then opening the stomach (gastrotomy) to remove the mass.
   • If there’s a “tail” extending into the intestine, it might be possible to pull it out through the stomach incision. If not, an additional incision in the small intestine may be necessary.

2. Psychological treatment:

   • Treating the underlying trichotillomania and trichophagia is crucial to prevent recurrence.
   • Cognitive-behavioral therapy is often the first-line treatment for trichotillomania.
   • Medications have shown limited effectiveness compared to behavioral therapy.

In the case study, the large trichobezoar was successfully removed surgically, and the child was referred for ongoing psychiatric follow-up.

Prevention and long-term outlook

Preventing trichobezoars primarily involves managing trichotillomania and trichophagia. This often requires long-term psychological care, as trichotillomania tends to be a chronic condition. However, with appropriate treatment, many people achieve remission or significant improvement in their symptoms.

For individuals with a history of trichotillomania or trichophagia, it’s important to be aware of the potential for trichobezoar formation. Any persistent abdominal symptoms should be evaluated by a healthcare provider.

The long-term outlook after trichobezoar removal is generally good, especially with proper psychological follow-up. However, without addressing the underlying hair-pulling and eating behaviors, there is a risk of recurrence.

Conclusions

• Trichobezoars are rare but potentially serious complications of trichotillomania and trichophagia.
• They can grow quite large before causing noticeable symptoms, making awareness and early detection crucial.
• Treatment typically involves surgical removal of the trichobezoar and ongoing psychological care to address the underlying behaviors.
• With proper treatment of both the physical and psychological aspects, the long-term outlook for patients with trichobezoars is generally positive.