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Case report
Management of a trichobezoar caused by consumption of artificial hair extensions
  1. Ria Emma Smith,
  2. Jaideep Singh Rait,
  3. Amira Said and
  4. Shwetal Dighe
  1. General Surgery, Darent Valley Hospital, Dartford, Kent, UK
  1. Correspondence to Dr Ria Emma Smith; ria.smith{at}nhs.net

Abstract

Trichobezoars are rare, but most commonly found in young women with trichophagia and trichotillomania. Complications can include iron deficiency anaemia and gastric erosion or, rarely, perforation. A 19-year-old woman presented with epigastric pain, vomiting and lethargy. Initial investigations revealed a palpable abdominal fullness on examination and iron deficiency anaemia. Oesophagogastroduodenoscopy found a large trichobezoar associated with gastric erosions, polyps and an ulcer. Subsequently, the patient reported previous consumption of artificial hair extensions, which ceased 5 years previously. Attempts to remove the trichobezoar by endoscopy were ineffective and in line with current literature, laparotomy was successful. This case describes a rare cause of trichobezoar and emphasises the importance of appropriate initial investigations and definitive management.

  • endoscopy
  • stomach and duodenum
  • gastrointestinal surgery
  • impulse control disorders

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Background

Gastric bezoars are defined as an accumulation of indigestible material forming a mass in the stomach. Bezoars composed of hair, or trichobezoars, are rare but most commonly found in young women with a history of psychiatric disorders such as trichophagia and trichotillomania (compulsive pulling and consumption of hair).1 Hair is caught between gastric folds and fails to move through the alimentary canal by peristalsis due to the smooth surface and is impacted with mucus and food. Rarely, hair can extend past the stomach into the jejunum, which is known as Rapunzel syndrome.

Examination may reveal an abdominal mass or halitosis caused by bacterial colonisation of the bezoar. Complications of trichobezoars include upper gastrointestinal bleeding and anaemia secondary to gastric mucosal erosion, perforation and rarely gastric outlet obstruction.2

We present an interesting presentation and subsequent management of a young woman with a trichobezoar caused by consumption of artificial hair extensions.

Case presentation

A 19-year-old woman presented to a district general hospital with a 1-day history of severe non-radiating epigastric pain and vomiting associated with 1 week of lethargy, which she attributed to personal stressors. She denied other associated symptoms including change in bowel habit, haematemasis or melaena and did not have urinary tract or gynaecological symptoms. The patient reported a medical history of gastritis with a previous negative Helicobacter Pylori test, which was treated with ranitidine by her general practitioner without endoscopic investigation. She did not report any psychiatric history.

On examination there was mild epigastric tenderness and a palpable fullness in the epigastrium, not consistent with hepatomegaly or splenomegaly.

Investigations

Blood tests revealed iron deficiency anaemia with haemoglobin of 70 g/L (which fell to 61 g/L) and iron <2.0 umol/L. The patient was initially given a blood transfusion and subsequently oral iron.

A plain abdominal film was reported as normal by a radiologist; however, retrospective review demonstrated a mottled appearance in the upper quadrants consistent with the final diagnosis. An abdominal ultrasound scan showed a distended, air filled stomach, but was otherwise normal.

An initial oesophagogastroduodenoscopy (OGD) was carried out in view of anaemia and epigastric symptoms. This revealed a large trichobezoar resulting in gastric erosions, gastric polyps up to 1.5 cm and a gastric ulcer of 1 cm. On further questioning, the patient and her family reported previous trichotillomania and consumption of artificial hair extensions, which stopped 5 years ago.

Treatment

Two attempts to remove the trichobezoar by endoscopy (first under sedation and then under general anaesthesia) were unsuccessful. Small amounts of hair were removed using a grasper, but this was abandoned due to risk of perforation. Definitive management was by laparotomy through which two large trichobezoars were removed from the fundus and body of the stomach, measuring 8×6 cm and 7×15 cm (figure 1).

Figure 1

Image showing two trichobezoars removed by laparotomy, 8×6 cm (left) and 7×15 cm (right).

Outcome and follow-up

The patient recovered well and was discharged with oral iron and omeprazole 1 week after laparotomy.

Discussion

Trichobezoars can be asymptomatic initially meaning that diagnosis is delayed, but then later present with abdominal pain, nausea and vomiting, anorexia and weight loss.1 Commonly, patients will report trichotillomania and trichophagia.1 In this case, only after diagnosis did the patient describe trichophagia ending 5 years previously, illustrating the possibility of an insidious presentation. Further still, the consumption of artificial hair leading to a trichobezoar is a unique aetiology scarcely reported in current literature, with a risk of increasing incidence along with the growing use of hair extensions.3–5

The British Society of Gastroenterology (BSG) recommends that iron deficiency anaemia in premenopausal women should be investigated with OGD if there are symptoms suggesting upper gastrointestinal disease.6 In this case, early imaging including abdominal radiograph and ultrasound did not identify a trichobezoar likely due to the rarity of such pathology. The only diagnostic intervention in this case was OGD, carried out due to iron deficiency anaemia and epigastric pain as per BSG guidelines.

In current literature, trichobezoars are rarely (5%) successfully removed endoscopically.7 In the majority of cases, endoscopy fails to remove the trichobezoar as a whole, and further trials of removal by fragmentation risk complications relating to repeated introduction of the endoscope, such as oesophagitis and ulceration.7 Laparoscopic removal has a higher success rate and is cosmetically more favourable but can be a complex procedure.7 The highest success rate (100%) has been reported with removal by laparotomy.7

Patient’s perspective

On arrival at hospital, after excruciating stomach pain and constant vomiting, a trichobezoar was the last thing I was expecting to be the issue at hand. My trichophagia began and ended at a young age, oblivious to the consequences of this, I was ingesting synthetic hair that I wore as braids. Due to the bleeding, I was very anaemic without knowledge, although I frequently took naps. Despite the amount of space taken up by the trichobezoars, I never felt a loss of appetite; however, I did notice more bloating than usual about a year before I was admitted in hospital.

After the trichobezoar was discovered, I was in two minds. On one hand I was grateful that the problem was found and therefore treatment could take place, but on the other hand, I was distraught at the fact I was facing the repercussions of something I did when I was young and naive.

Moving onward, due to the failed endoscopy attempts and my unfavourable experience, it was agreed that a laparotomy to retrieve the trichobezoar was the best option with the highest success rate. I left hospital after a course of 2 weeks, after about a week I felt much better, still considering I had to take it slow.

Learning points

  • Trichobezoars can present insidiously, years after trichophagia.

  • Trichobezoars can rarely be formed from artificial hair, but this unique aetiology may become more common with increasing use of artificial hair extensions.

  • Early upper gastrointestinal endoscopy is a necessity in premenopausal patients presenting with iron deficiency anaemia and upper gastrointestinal symptoms.

  • Endoscopic removal of trichobezoars is rarely successful, so consider laparoscopy or laparotomy early.

References

Footnotes

  • Contributors The patient was under the care of SD. Case report was written and reviewed by RES, JSR and AS and supervised by SD.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.