Case notes

A 17-year-old primigravida at the end of her first trimester was referred for evaluation of a well-defined, firm, mobile mass in the epigastric region. She had a recent history of upper abdominal pain and vomiting; her medical history revealed that she had a long-term anxiety disorder and the occasional habit of eating bits of her own hair.

After stabilization, the patient underwent magnetic resonance imaging (MRI). This disclosed a large intraluminal gastric mass with extreme distension of the stomach. An upper gastrointestinal endoscopy confirmed the large mass was composed of hair and residual food with debris. The gastric walls appeared normal, and the duodenum could not be visualized.

Conclusions

A midline laparotomy was performed, the stomach was delivered, and a large trichobezoar was removed via gastrotomy ( Figure , A). The mass extended as far as the second part of the duodenum but did not reach distally to the small bowel.

The patient presented with a palpable mass. A , This was removed via laparotomy and gastrotomy. B , When the mass was investigated, magnetic resonance imaging disclosed a normal live intrauterine pregnancy of approximately 12 weeks’ gestation.

Ramdass. A Grimm situation. Am J Obstet Gynecol 2011.

Trichobezoar was first reported in 1779 by Baudamant. The word originates from 2 stems: trich and bezoar, with the former meaning hair in Greek, and the latter meaning poison antidote in Arabic or Persian. The presence of trichobezoar in pregnancy is a rare and challenging issue, with only a handful of papers published on the topic. Associations include anxiety or obsessive-compulsive disorders causing trichotillomania (hair pulling) and trichophagia (hair eating). Rapunzel syndrome, described in 1968, is an extension of a gastric trichobezoar into the small gut in the form of a long tail. Named after Rapunzel, the heroine of a German fairy tale by the Grimm brothers, it has been infrequently reported in pregnancy with only 24 cases to date.

Hair entrapment in the gastric folds is believed to be the initiating event. Due to its indigestibility, resilience, and slippery nature, hair becomes enmeshed within the mucosal folds, and as more hairs are acquired, the trichobezoar grows larger. The clinical picture ranges from abdominal pain, nausea, vomiting, early satiety, and weight loss to bleeding, intestinal obstruction, perforation, intussusception, and pancreatitis.

Diagnostic modalities for pregnant women include ultrasound, upper endoscopy, and MRI. On an MRI scan, the trichobezoar appears in the stomach region as a well-circumscribed lesion composed of concentric whorls of different densities and pockets of air. While computed tomography is highly accurate, it is contraindicated during pregnancy. Treatment is surgical removal of the trichobezoar with preservation of the pregnancy. In some emergent scenarios, the mother’s life will take priority. The use of laparoscopic techniques has been reported.

Hopefully, this case highlights the issues associated with trichobezoar and the potential options for investigation and management from obstetric, surgical, and psychiatric perspectives. Our patient developed a wound infection, but had an otherwise uneventful recovery. At the time of surgery, a normal live intrauterine pregnancy of approximately 12 weeks’ gestation was documented with MRI ( Figure , B). Her pregnancy continued to term and concluded with normal delivery of a healthy baby. She was referred to the psychiatric unit for counseling after surgery.