Scholarly article on topic 'Trichophagia along with trichobezoar in the absence of trichotillomania'

Trichophagia along with trichobezoar in the absence of trichotillomania Academic research paper on "Clinical medicine"

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Academic research paper on topic "Trichophagia along with trichobezoar in the absence of trichotillomania"

Case Report

Trichophagia along with trichobezoar in the absence of trichotillomania

Aseem Mehra, Ajit Avasthi, Vikas Gupta1, Sandeep Grover

Department of Psychiatry and Surgery1, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India


Trichobezoars are rarely described in the absence of trichotillomania. In this report we present a case of trichobezoar associated with trichophagia in the absence of trichotillomania. A 16-year-old girl presented to surgery outpatient with complaints of pain in abdomen and vomiting for the last 6 months. Physical examination revealed a 14 x 16 cm firm, tender, mass with smooth surface, irregular margins, which was mobile with respiration. Ultrasound abdomen revealed a bizarre lesion in the right upper and middle abdomen suggestive of gastric bezoars. Upper gastrointestinal endoscopy did not reveal any abnormality in the esophagus and showed a large mobile mass in the stomach. In view of trichobezoar, psychiatry consultation was sought. Exploration of history revealed that the patient was eating hairs and clay since early childhood. As per patient she would eat hairs thrown by others. She would like the taste of hair and had strong persistent desire to eat hair and would go out searching for the same. At times she would also eat clay. However, she denied of pulling her own hairs. Physical examination of scalp and other body parts did not show any evidence of alopecia or pulling of hair/short hair. She was managed surgically and was counseled about the consequences of eating hairs and clays and was encouraged not to eat hair. To conclude our case suggests that patients can have trichobezoar and trichophagia even in the absence of trichotillomania.

Key words: Trichophagia, trichotillomania, trichobezoar


Trichophagia is understood as a compulsive behavior involving eating hairs, usually of own. Trichobezoars are concretions of mostly hair, which accumulate in the gastrointestinal tract. Trichobezoars are often associated with psychiatry disorder like trichotillomania, mental retardation, emotional disturbances and/or pica.[1] Most of the cases of trichobezoars are described in adolescent girls/young females.[2,3]

However, trichophagia and trichobezoars are rarely described in the absence of trichotillomania.^ In this case report we describe a case of trichobezoar associated with trichophagia in the absence of trichotillomania.

Case Report

A 16-year-old single girl, with 10 years of formal education, from rural background presented to surgery outpatient with complaints of pain in abdomen and vomiting for the last 6 months. She would have frequent bouts of vomiting, frequency of which increased in the last few days prior to presentation. On physical examination, she was found to have a mobile mass of 14 x 16 cm size in the upper abdomen, which was tender, with smooth surface and irregular margins. Ultrasound abdomen revealed a bizarre lesion in the right upper and middle abdomen suggestive of gastric bezoars. Upper gastrointestinal endoscopy did not reveal any abnormality in the esophagus and a large mobile mass made of hairs was seen in the stomach. Based on the findings of ultrasound and upper gastrointestinal endoscopy, a diagnosis of trichobezoar was considered and psychiatry consultation was sought. Psychiatric evaluation revealed that the girl was eating hairs and clay since early childhood. She would eat the hairs thrown here and there by her mother, other family members and neighbors. The patient would like the taste of hairs and had a strong and persistent desire to eat hairs. She would

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Dr. Sandeep Grover, Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012, Punjab and Haryana, India. E-mail:

often go out searching for the same. Additionally, at times she would also eat clay. The description of the patient was corroborated by the mother too; who described that despite persistence reprimands, the patient persisted to eat hairs and occasionally would eat clay. However, the patient denied pulling out her own hairs. Physical examination of scalp and other body parts did not reveal any evidence of alopecia or pulling of hair/short hair. Past history did not reveal any evidence of depressive disorders, obsessive compulsive disorder, other anxiety disorders, eating disorders, emotional disturbances, mental sub-normality and other impulse control disorders. Also, there was no family history of any mental illness. Investigations in the form hemoglobin level, complete blood counts, serum electrolytes, liver function test, renal function test, pancreatic enzymes and routine stool examination did not reveal any abnormality. In view of large size of the mass, open laparotomy was done and the mass was removed. On examination, the mass comprised of entangled hairs. A psychiatric diagnosis of other behavioral and emotional disorders with onset usually occurring in childhood and adolescence (Pica of infancy and childhood) as per the ICD-10 was considered. The patient was counseled against eating hairs and clays and was informed about the consequences of the same. Behavioral analysis revealed that the patient would have urge to eat hair more so, when under stress. Additionally, behavioral principles with regards to management of urge and impulse control were discussed. Additionally, the psychotherapeutic intervention focused on teaching adaptive coping skills to deal with the stressful situations. Family members were also educated about the illness and were asked to be vigilant to note the patient behavior of eating hairs and other non-eatable items. The patient improved after the surgery and follow-up at 6 months did not reveal any behavior suggestive of trichophagia or pica.


The term "Bezoar" is understood to be derived from the Arabic word "Bazehr" or the Persian word "Padzhar," which are used for antidote, because traditionally stones from the stomach or intestine of various animals were considered to have medicinal value.[5] Different types of bezoars are described in humans and according to the composition are named as phytobezoar (containing vegetable fibres), lactobezoar (milk products), pharmacobezoar (medications) and trichobezoar (hairs).[15] Additionally bezoars composed of cotton and other materials have also been described in the literature.[3] Usually the bezoars are found in the stomach, however, when the tail of the bezoar extends beyond the

pylorus and involves the duodenum or further lower gastrointestional tract, it is known as Rapunzel syndrome.[6] In terms of pathogenesis of trichobezoar, it is believed that because of its smooth surface the hairs do not move forward with the peristaltic movement and resultantly get accumulated.[7]

Trichophagia and trichobezoar are abundantly described in surgical literature.[115] In few cases, no evidence of trichotillomania was found in patients presenting with trichobezoar.[4,9] Previous reports of trichobezoar have also reported co-occurrence of eating hairs and other non-eatable items amounting to pica.[8] Pica is understood as a clinical condition in which the subjects often eats non-nutritive materials like soil, dirt, hairballs, ice, paint and sand, etc., It is usually seen in the setting of low intelligence;[16] however, it can also occur in children with normal intelligence.[16]

As trichobezoar is often associated with trichotillomania and eating of other non-eatable items which can amount to pica, a psychiatric evaluation of such patients is recommended. Although trichotillomania itself is considered to be an impulse control disorder, it may also manifest as a symptom of many other mental disorders. Accordingly detail psychiatric evaluation to focus on ruling trichotillomania and other psychiatric disorders. Detail physical examination should involve looking for patches of hair loss in various parts of the body. A patient may have pica and also trichotillomania as a manifestation of low intelligence. Accordingly if low intelligence is suspected, the patient intelligence quotient must be assessed. In view of the associated pica, these patients must be evaluated for iron deficiency. Management of trichotillomania and pica involves psychoeducation, behavior therapy (habit reversal therapy in case patient has trichotillomania) and teaching adaptive coping skills. Patients with trichobezoar must be followed up regularly because of the risk of recurrence.[1112]

Most of the cases of trichophagia and trichobezoar are described in patients with trichotillomania, which is considered to be an impulsive control disorder or other psychiatric disorders. Index case had no psychiatric history, any evidence of psychological distress or specific personality traits which could be considered to be associated with trichophagia. The present case exemplifies that patients of trichobezoar can have isolated trichophagia. Hence, the absence of trichotillomania should not be considered to be equivalent of absence of trichophagia.


1. Gonuguntla V, Joshi DD. Rapunzel syndrome: A comprehensive review of an unusual case of trichobezoar. Clin Med Res 2009;7:99-102.

2. De Bakey M, Ochsner W Bezoars and concretions: A comprehensive review of the literature with an analysis of 303 collected cases and a presentation of 8 additional cases. Surgery 1938;4:934-63.

3. Chintamani, Durkhure R, Singh JP, Singhal V. Cotton bezoar—a rare cause of intestinal obstruction: Case report. BMC Surg 2003;3:5.

4. Tiago S, Nuno M, Joao A, Carla V, Gongalo M, Joana N. Trichophagia and trichobezoar: Case report. Clin Pract Epidemiol Ment Health 2012;8:43-5.

5. Williams RS. The fascinating history of bezoars. Med J Aust 1986;145:613-4.

6. Memon SA, Mandhan P, Qureshi JN, Shairani AJ. Recurrent Rapunzel syndrome-a case report. Med Sci Monit 2003;9:CS92-4.

7. Frey AS, McKee M, King RA, Martin A. Hair apparent: Rapunzel syndrome. Am J Psychiatry 2005;162:242-8.

8. Western C, Bokhari S, Gould S. Rapunzel syndrome: A case report and review. J Gastrointest Surg 2008;12:1612-4.

9. Islek A, Sayar E, Yilmaz A, Boneval C, Artan R. A rare outcome of

iron deficiency and pica: Rapunzel syndrome in a 5-year-old child iron deficiency and pica. Turk J Gastroenterol 2014;25:100-2.

10. Gurzu S, Jung I. Gastric tricho-wool bezoar in an 18-year-old girl. S Afr J Surg 2013;51:33-4.

11. Kirpinar I, Kocacenk T, Koger E, Memmi N. Recurrent trichobezoar due to trichophagia: A case report. Gen Hosp Psychiatry 2013;35:439-41.

12. Tiwary SK, Kumar S, Khanna R, Khanna AK. Recurrent Rapunzel syndrome. Singapore Med J 2011;52:e128-30.

13. Jain M, Solanki SL, Bhatnagar A, Jain PK. An unusual case report of Rapunzel syndrome trichobezoar in a 3-year-old boy. Int J Trichology 2011;3:102-4.

14. Kim JS, Nam CW A case of Rapunzel syndrome. Pediatr Gastroenterol Hepatol Nutr 2013;16:127-30.

15. Prasanna BK, Sasikumar K, Gurunandan U, Sreenath GS, Kate V. Rapunzel syndrome: A rare presentation with multiple small intestinal intussusceptions. World J Gastrointest Surg 2013;5:282-4.

16. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization; 1992.

How to cite this article: Mehra A, Avasthi A, Gupta V, Grover S. Trichophagia along with trichobezoar in the absence of trichotillomania. J Neurosci Rural Pract 2014;5:55-7.

Source of Support: Nil. Conflict of Interest: None declared.


Independently by their location, bezoars are defined as concretions of undigestible materials. In most of the cases they occur in stomach or intestines, being composed by hair (trichobezoar), indigestible vegetables or fruits (phytobezoar-general term, diospyrobezoar-tannin-containing persimmon fibers), milk products (lactobezoar), drugs (pharmacobezoar), cotton, sand, metal, plastic, chemically-transformed gloves, and even wool, as in one of our previous reported cases in a post-partum young girl.[1] In the gastrointestinal tract, most of the cases occurred in patients with diagnosed or even unknown psychiatric disorders such as trichophagia, trichotillomania, pica, emotional disorders, schizophrenia, etc.[1]

Compared with the bezoars of the gastrointestinal tract, few cases have been reported in field of urology. Obstruction of the pelviureteric tract can be even produced by foreign materials, such as an indwelling ureteral stent forgotten in a renal transplant patient,1[2] or by concretions of endogen undigestible materials.[3-7] To our best knowledge, bezoars of the kidney and urinary tract can occur as a result of at least three main causes. First of all, a severe renal failure can lead to synchronous renal and intestinal deposits of drugs (renal and intestinal pharmacobezoars), first case being reported in 1973.[3]

Second cause and the most frequent one is the fungal bezoar, it being especially related to Candida albicans

but Aspergillus fumigatus and other types of fungi such as Rhizopus were also reported as a cause for these renal concretions, with or without involvement of renal parenchyma.[4-7] Independently by the type of fungus, fungal balls of the kidney have especially been reported in neonates and premature infants, they being sometimes associated with bilateral pelviureteric obstruction and consecutive anuria and urinary asdte.[4/6] These fungal concretions were especially related to immunosuppression, treatment with antibiotics, and using of intravenous or urinary catheters.[4] Pelviureteral aspergilloma is an opportunistic lesion that can occur in diabetics or other patients with impaired immunity, leading also to uni-or bilateral ureteric obstruction[5] and renal abscesses.[6] Aspergilloma of the urinary tract is usually a secondary spread from pulmonary aspergillosis while candida bezoars occur in cases with systemic candidiasis and Rhizopus is a manifestation of zygomycosis.[4-7] Primary renal aspergilloma and xanthogranulomatous pyelonephritis have also been reported in immunocompetent patients.[6] Till July 2014, about 65 cases of fungal bezoars of the urinary tract were reported, one third of them being related to aspergillosis.[5,6]

A third and more rare cause of obstruction of the renal tubes with or without involvement of the pelviureteric structures were reported in association with poisonings. A strange case, for example, led to death of an adult

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