Trichobezoar (Hair Bezoar): Advanced Clinical, Imaging, and Management Insights.

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https://doi.org/10.1056/NEJMicm1403124

Introduction: Understanding Trichobezoar in Clinical Practice

Trichobezoar, commonly referred to as a hair bezoar, is a rare but clinically significant gastrointestinal condition characterized by the accumulation of ingested hair within the stomach and sometimes extending into the small intestine. This condition is strongly associated with psychiatric disorders such as trichotillomania and trichophagia, making it a fascinating intersection between gastroenterology, radiology, and psychiatry. 

This column provides a comprehensive, expert-level yet reader-friendly analysis of trichobezoar, integrating real case imaging findings, pathophysiology, and diagnosis.

https://doi.org/10.4021/gr2008.11.1287

Case Overview: 18-Year-Old Female with Abdominal Pain and Vomiting

An 17-year-old female with a known history of autism and trichotillomania presented with:

  • Persistent vomiting for 48 hours
  • Abdominal pain
  • Normal vital signs and laboratory findings

Imaging Findings

Contrast-enhanced abdominal CT revealed a heterogeneous, mesh-like intragastric mass extending from the stomach into the duodenum, consistent with a trichobezoar.

Figure Interpretation

Figure 1. Axial CT Image

  • Demonstrates a heterogeneous intraluminal mass within the stomach
  • Appears as a low-density, mottled structure with trapped air
  • Caption: Axial CT showing the characteristic mesh-like appearance of trichobezoar extending within the gastric lumen

Figure 2. Coronal CT Image

  • Shows extension of the bezoar into the duodenum
  • Suggests possible Rapunzel syndrome (tail extending beyond the stomach)
  • Caption: Coronal CT revealing an elongated trichobezoar extending from the stomach to the duodenum

Pathophysiology of Trichobezoar

Trichobezoar formation involves several mechanisms:

  1. Ingestion of Hair (Trichophagia)
    Hair is indigestible due to its keratin composition.
  2. Accumulation in Gastric Folds
    Hair strands resist peristalsis and become trapped.
  3. Aggregation Over Time
    Hair entangles with mucus and food particles.
  4. Compaction into a Dense Mass
    Leads to the formation of a gastric bezoar.

Hair’s smooth surface prevents propulsion, allowing progressive enlargement, sometimes forming a cast of the stomach and small intestine.

Epidemiology of Trichobezoar

  • Predominantly affects young females (age 10–20 years)
  • Strong association with:
    • Psychiatric disorders
    • Developmental disorders (e.g., autism)
  • Rare condition, but likely underdiagnosed

Clinical Presentation

Common symptoms include:

  • Abdominal pain
  • Nausea and vomiting
  • Early satiety
  • Weight loss
  • Palpable abdominal mass

Severe cases may present with:

  • Gastric outlet obstruction
  • Intestinal obstruction
  • Perforation (rare but life-threatening)

Imaging Features of Trichobezoar

CT Scan (Gold Standard)

Key findings:

  • Well-defined intraluminal mass
  • Heterogeneous density
  • Mottled gas pattern (“mesh-like appearance”)
  • Extension into the small bowel (Rapunzel syndrome)

Ultrasound

  • Hyperechoic mass with acoustic shadowing

Endoscopy

  • Direct visualization of hair mass
  • Diagnostic and sometimes therapeutic

Differential Diagnosis

Important conditions to distinguish from trichobezoar:

  1. Gastrointestinal stromal tumor (GIST)
  2. Pancreatic phlegmon
  3. Subphrenic abscess
  4. Severe constipation (fecal impaction)
  5. Phytobezoar (plant-based bezoar)

However, the characteristic CT mesh-like pattern strongly favors trichobezoar.

Diagnosis of Trichobezoar

Diagnosis is based on:

  • Clinical suspicion (psychiatric history)
  • Imaging (CT scan)
  • Endoscopic confirmation

Treatment of Trichobezoar

1. Non-Surgical Management

  • Enzymatic dissolution (e.g., papain)
  • Often ineffective for hair bezoars

2. Endoscopic Removal

  • Suitable for small bezoars
  • Limited success in large trichobezoars

3. Surgical Treatment (Gold Standard)

  • Laparotomy or laparoscopy
  • Complete removal of the bezoar
  • Necessary for large or complicated cases

Case Outcome:
Endoscopic attempts failed; the patient underwent open surgical removal, extracting a large trichobezoar spanning the stomach to the jejunum.

Prognosis

  • Generally excellent after removal
  • Recurrence is possible if the psychiatric condition is untreated

Key Prevention Strategy

  • Psychiatric intervention
  • Behavioral therapy

Quiz Section

Question 1. What is the most likely diagnosis based on CT showing a mesh-like intragastric mass?

A. Gastrointestinal stromal tumor
B. Pancreatic phlegmon
C. Subphrenic abscess
D. Obstipation
E. Trichobezoar

Answer: E. Explanation: The heterogeneous mesh-like pattern is classic for trichobezoar.

Question 2. Which condition is most commonly associated with trichobezoar?

A. Diabetes mellitus
B. Trichotillomania
C. Hypertension
D. Crohn’s disease
E. Peptic ulcer disease

Answer: B. Explanation: Trichobezoar is strongly linked to trichotillomania and trichophagia.

Question 3. What is the most effective treatment for large trichobezoars?

A. Antibiotics
B. Observation
C. Endoscopic removal
D. Surgical removal
E. Chemotherapy

Answer: D. Explanation: Large bezoars require surgical removal due to size and risk of obstruction.

Conclusion

Trichobezoar is a rare but diagnostically distinctive condition with hallmark imaging findings and strong psychiatric associations. Early recognition using CT imaging, followed by appropriate surgical management, ensures excellent outcomes. However, long-term success depends on addressing underlying behavioral disorders, making multidisciplinary care essential.

Recommended Reading 

  1. Gonuguntla V, Joshi DD. Rapunzel Syndrome: A Comprehensive Review. Gastroenterology Research. 
  2. Naik S et al. Rapunzel syndrome reviewed and redefined. Dig Surg. DOI: https://doi.org/10.1159/000073997
  3. Ripollés T et al. Gastrointestinal bezoars: Sonographic and CT characteristics. AJR. DOI: https://doi.org/10.2214/ajr.172.2.9930797
  4. Ventura DE et al. Trichobezoar: Case report and literature review. Int J Surg Case Rep. DOI: https://doi.org/10.1016/j.ijscr.2017.01.034
  5. Gorter RR et al. Management of bezoars. J Pediatr Surg. DOI: https://doi.org/10.1016/j.jpedsurg.2010.03.019
  6. Erzurumlu K et al. Gastrointestinal bezoars: Analysis of 34 cases. World J Gastroenterol. DOI: https://doi.org/10.3748/wjg.v11.i12.1813

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