🩺 FCPS Paediatrics TOACS · Bezoars (Nelson Chapter 380.2)
📖 Nelson's Textbook of Pediatrics · Trichobezoar · Rapunzel Syndrome · Trichotillomania · Endoscopic & Surgical Management
📚 paeds.online – Paeds Online
🩺 OBSERVED/INTERACTIVE STATION · CPSP FORMAT · 8 MINUTES · Trichobezoar: hair pulling + vomiting + weight loss + barium filling defect
📋 Observed Station – “Adolescent girl with hair pulling, vomiting, weight loss, and bezoar”
👩🏻 Clinical Scenario (TOACS – read aloud / displayed):
A 13‑year‑old girl presents with persistent vomiting, abdominal pain, and progressive weight loss over the past 3 months. On further questioning, the mother admits that the patient has a long‑standing habit of pulling out her hair (trichotillomania) and secretly swallowing it. On examination, the patient is pale and cachectic. Abdominal examination reveals a firm, non‑tender, mobile epigastric mass.
Barium study (upper GI series): A large filling defect is seen in the stomach with persistent barium within the interstices of the mass, extending into the duodenum and proximal jejunum on delayed films – classic for a trichobezoar with an extension (Rapunzel syndrome).
🎯 Task (examiner observed): Recognize the condition as a trichobezoar (Rapunzel syndrome). Explain the pathophysiology (hair ingestion, intestinal obstruction). Discuss differential diagnosis (phytobezoar, tumor, Crohn). Describe management: endoscopic removal for small bezoars, surgical removal (gastrotomy) for large trichobezoars with extension. Address the underlying psychiatric condition (trichotillomania) and the need for psychiatric referral.
📸 Barium study showing trichobezoar with tail extending into duodenum
A 13‑year‑old girl presents with persistent vomiting, abdominal pain, and progressive weight loss over the past 3 months. On further questioning, the mother admits that the patient has a long‑standing habit of pulling out her hair (trichotillomania) and secretly swallowing it. On examination, the patient is pale and cachectic. Abdominal examination reveals a firm, non‑tender, mobile epigastric mass.
Barium study (upper GI series): A large filling defect is seen in the stomach with persistent barium within the interstices of the mass, extending into the duodenum and proximal jejunum on delayed films – classic for a trichobezoar with an extension (Rapunzel syndrome).
🎯 Task (examiner observed): Recognize the condition as a trichobezoar (Rapunzel syndrome). Explain the pathophysiology (hair ingestion, intestinal obstruction). Discuss differential diagnosis (phytobezoar, tumor, Crohn). Describe management: endoscopic removal for small bezoars, surgical removal (gastrotomy) for large trichobezoars with extension. Address the underlying psychiatric condition (trichotillomania) and the need for psychiatric referral.
📸 Barium study showing trichobezoar with tail extending into duodenum
Figure: Barium contrast study showing a large filling defect in the stomach with barium trapped within the interstices of the trichobezoar. The 'tail' extends into the duodenum and proximal jejunum – classic for Rapunzel syndrome.
⚠️ CLINICAL PEARLS (Nelson Ch.380.2):
• Trichobezoar = hair ball in the stomach (most common in adolescent females with trichotillomania/trichophagia).
• Rapunzel syndrome: Trichobezoar with a tail extending beyond the stomach into the duodenum or jejunum → can cause obstruction, perforation, or pancreatitis.
• Classic presentation: Abdominal pain, vomiting, weight loss, early satiety, epigastric mass, halitosis.
• Alopecia/trichotillomania may be evident on scalp examination.
• Barium study / CT / endoscopy confirms diagnosis (filling defect, trapped contrast).
• Management: Endoscopic removal (small) or surgical gastrotomy (large). Treat underlying trichotillomania with psychiatric support (CBT, SSRIs).
• Trichobezoar = hair ball in the stomach (most common in adolescent females with trichotillomania/trichophagia).
• Rapunzel syndrome: Trichobezoar with a tail extending beyond the stomach into the duodenum or jejunum → can cause obstruction, perforation, or pancreatitis.
• Classic presentation: Abdominal pain, vomiting, weight loss, early satiety, epigastric mass, halitosis.
• Alopecia/trichotillomania may be evident on scalp examination.
• Barium study / CT / endoscopy confirms diagnosis (filling defect, trapped contrast).
• Management: Endoscopic removal (small) or surgical gastrotomy (large). Treat underlying trichotillomania with psychiatric support (CBT, SSRIs).
🧠 TYPES OF BEZOARS (Nelson Ch.380.2):
• Phytobezoar: Most common – undigested vegetable/fruit matter (persimmons, pumpkins, celery).
• Trichobezoar: Hair – associated with trichotillomania and trichophagia.
• Lactobezoar: In premature infants (curdled milk) – often resolves with holding feeds.
• Pharmacobezoar: Medication concretions (e.g., enteric‑coated tablets).
• Rapunzel syndrome: Trichobezoar with a tail extending into the small intestine.
• Phytobezoar: Most common – undigested vegetable/fruit matter (persimmons, pumpkins, celery).
• Trichobezoar: Hair – associated with trichotillomania and trichophagia.
• Lactobezoar: In premature infants (curdled milk) – often resolves with holding feeds.
• Pharmacobezoar: Medication concretions (e.g., enteric‑coated tablets).
• Rapunzel syndrome: Trichobezoar with a tail extending into the small intestine.
💡 Examiner instruction (observed station): Candidate must (1) diagnose trichobezoar/Rapunzel syndrome, (2) describe imaging findings (barium filling defect with tail), (3) differentiate from other bezoars and tumors, (4) explain that surgical removal (gastrotomy) is needed for large trichobezoars, (5) stress the importance of psychiatric evaluation (trichotillomania), and (6) discuss post‑operative nutritional support and prevention of recurrence.
🔬 Diagnosis & Differential (Bezoars)
1 History & physical
Trichotillomania/trichophagia, epigastric mass, halitosis, early satiety, alopecia.
Trichotillomania/trichophagia, epigastric mass, halitosis, early satiety, alopecia.
2 Barium upper GI series
Filling defect in stomach, barium trapped in the interstices of the bezoar, tail extending into duodenum/jejunum (Rapunzel syndrome).
Filling defect in stomach, barium trapped in the interstices of the bezoar, tail extending into duodenum/jejunum (Rapunzel syndrome).
3 CT abdomen
Heterogeneous intraluminal mass with trapped air, may show extension.
Heterogeneous intraluminal mass with trapped air, may show extension.
4 Upper endoscopy (EGD)
Visualizes the bezoar, allows biopsy to rule out malignancy, and may permit endoscopic removal of small bezoars.
Visualizes the bezoar, allows biopsy to rule out malignancy, and may permit endoscopic removal of small bezoars.
5 Psychiatric evaluation
Screen for trichotillomania, anxiety, depression, or eating disorders.
Screen for trichotillomania, anxiety, depression, or eating disorders.
📋 DIFFERENTIAL DIAGNOSIS (abdominal mass + weight loss + vomiting):
• Gastric outlet obstruction (pyloric stenosis, antral web).
• Gastric malignancy (lymphoma, adenocarcinoma – rare in children).
• Crohn disease (strictures, weight loss, abdominal pain).
• Celiac disease (malabsorption, weight loss, but no mass).
• Superior mesenteric artery (SMA) syndrome (postprandial vomiting).
• Chronic gastritis / peptic ulcer (pain, vomiting, but no mass).
• Omental or mesenteric cyst (palpable mass, but no hair ingestion).
• Gastric outlet obstruction (pyloric stenosis, antral web).
• Gastric malignancy (lymphoma, adenocarcinoma – rare in children).
• Crohn disease (strictures, weight loss, abdominal pain).
• Celiac disease (malabsorption, weight loss, but no mass).
• Superior mesenteric artery (SMA) syndrome (postprandial vomiting).
• Chronic gastritis / peptic ulcer (pain, vomiting, but no mass).
• Omental or mesenteric cyst (palpable mass, but no hair ingestion).
🩺 ENDOSCOPIC vs SURGICAL REMOVAL (Nelson Ch.380.2):
• Endoscopic removal: For small (<2-3 cm) phytobezoars or small trichobezoars. Use of snares, forceps, fragmentation. May require multiple sessions.
• Surgical removal: For large trichobezoars (especially those >5-6 cm or with tail). Gastrotomy with extraction of the bezoar. If the tail extends far into the small bowel, an enterotomy may be needed. Laparoscopic removal is increasingly used.
• Endoscopic fragmentation with Coca‑Cola (for phytobezoars – not effective for hair).
• Prokinetics (metoclopramide, erythromycin) may help small bezoars but are not primary therapy for trichobezoars.
• Endoscopic removal: For small (<2-3 cm) phytobezoars or small trichobezoars. Use of snares, forceps, fragmentation. May require multiple sessions.
• Surgical removal: For large trichobezoars (especially those >5-6 cm or with tail). Gastrotomy with extraction of the bezoar. If the tail extends far into the small bowel, an enterotomy may be needed. Laparoscopic removal is increasingly used.
• Endoscopic fragmentation with Coca‑Cola (for phytobezoars – not effective for hair).
• Prokinetics (metoclopramide, erythromycin) may help small bezoars but are not primary therapy for trichobezoars.
🗨️ Examiner Q&A · Trichobezoar · Rapunzel Syndrome · Management · Psychiatric
❓ Q1 (Examiner): “What is the most likely diagnosis in this 13‑year‑old girl with hair pulling, vomiting, weight loss, and barium filling defect?”
✅ Trichobezoar with Rapunzel syndrome. The combination of trichotillomania/trichophagia, persistent vomiting, weight loss, a palpable epigastric mass, and barium study showing a filling defect with a tail extending into the duodenum/jejunum is classic for Rapunzel syndrome (trichobezoar extending beyond the stomach).
❓ Q2 (Examiner): “What is Rapunzel syndrome?”
✅ Rapunzel syndrome is a trichobezoar that has a long tail extending beyond the stomach into the duodenum, jejunum, or even ileum. It is named after the fairy tale character Rapunzel because of the 'tail' of hair. This can cause intestinal obstruction, perforation, pancreatitis, or intussusception.
❓ Q3 (Examiner): “What is the underlying psychiatric condition, and how do you manage it?”
✅ Trichotillomania (hair‑pulling disorder) with trichophagia (hair eating). It is classified under obsessive‑compulsive and related disorders.
Management:
1. Psychiatric referral: Cognitive‑behavioral therapy (CBT) – habit reversal training (HRT) is the most effective.
2. Pharmacotherapy: SSRIs (fluoxetine, sertraline), clomipramine (for OCD features).
3. Family education and support – reduce guilt and shame, encourage adherence.
4. Monitor for recurrence – trichobezoars can recur after surgery if behavior continues.
Management:
1. Psychiatric referral: Cognitive‑behavioral therapy (CBT) – habit reversal training (HRT) is the most effective.
2. Pharmacotherapy: SSRIs (fluoxetine, sertraline), clomipramine (for OCD features).
3. Family education and support – reduce guilt and shame, encourage adherence.
4. Monitor for recurrence – trichobezoars can recur after surgery if behavior continues.
❓ Q4 (Examiner): “How do you differentiate trichobezoar from phytobezoar on imaging?”
✅ Trichobezoar: Barium study shows a filling defect with trapped barium within the interstices (moth‑eaten appearance). CT shows a heterogeneous intraluminal mass with trapped air. The tail is characteristic of Rapunzel syndrome.
Phytobezoar: Also a filling defect, but often more irregular and less likely to have a tail. High‑density on CT without the hair‑like appearance. History of fruit/vegetable ingestion (e.g., persimmons).
Phytobezoar: Also a filling defect, but often more irregular and less likely to have a tail. High‑density on CT without the hair‑like appearance. History of fruit/vegetable ingestion (e.g., persimmons).
❓ Q5 (Examiner): “What is the definitive treatment for a large trichobezoar with tail?”
✅ Surgical removal via gastrotomy (or laparoscopy). The bezoar is extracted through a longitudinal incision in the stomach. If the tail extends into the small bowel, an enterotomy may be needed. The mass is removed en bloc or fragmented if necessary. Endoscopic removal is not feasible for large trichobezoars (>5 cm or with tail).
❓ Q6 (Examiner): “Can trichobezoar be managed endoscopically?”
✅ Yes, for small trichobezoars (<2-3 cm) that are not densely packed. Endoscopic removal uses snares, forceps, baskets, or fragmentation devices. May require multiple sessions. However, large trichobezoars (especially those >5 cm or with Rapunzel tail) require surgery. Endoscopic removal of hair bezoars is often difficult due to their firm, compact nature.
❓ Q7 (Examiner): “What complications can a trichobezoar cause?”
✅ Complications include:
• Gastric outlet obstruction (vomiting, early satiety).
• Small bowel obstruction (if the tail acts as a lead point or intussusception).
• Malnutrition, weight loss, iron deficiency anemia (due to chronic blood loss from gastric irritation).
• Gastric ulceration and perforation (rare).
• Pancreatitis (if the tail obstructs the ampulla).
• Intussusception (small bowel).
• Gastric outlet obstruction (vomiting, early satiety).
• Small bowel obstruction (if the tail acts as a lead point or intussusception).
• Malnutrition, weight loss, iron deficiency anemia (due to chronic blood loss from gastric irritation).
• Gastric ulceration and perforation (rare).
• Pancreatitis (if the tail obstructs the ampulla).
• Intussusception (small bowel).
❓ Q8 (Examiner): “What is the role of Coca‑Cola / enzymatic dissolution in bezoar management?”
✅ For phytobezoars – Coca‑Cola or cellulase can help dissolve vegetable/fruit bezoars. The carbonation and acidity help break down the fibrous material. However, trichobezoars (hair) are resistant to chemical dissolution and require mechanical removal (endoscopic or surgical). Papain (meat tenderizer) is no longer recommended due to risk of gastric ulceration and perforation.
❓ Q9 (Examiner): “The parents ask: ‘Could this be cancer?’ – How do you respond?”
✅ “Based on the history of hair pulling and swallowing, the imaging findings are classic for a trichobezoar (hair ball). This is not a cancer. It is a benign accumulation of hair in the stomach. The weight loss and vomiting are due to obstruction caused by the bezoar, not malignancy. After surgical removal, she will recover, and we will also address the underlying hair‑pulling behavior with psychiatric support.”
❓ Q10 (Examiner): “What is the risk of recurrence after surgical removal?”
✅ Recurrence is high (30-50%) if the underlying trichotillomania/trichophagia is not addressed. Therefore, post‑operative psychiatric follow‑up is essential. Behavioral therapy (habit reversal training) and SSRIs can reduce recurrence. Regular follow‑up with the pediatric gastroenterologist and psychiatrist is recommended.
📢 Examiner probe (counseling): “The mother feels guilty and asks if she could have prevented it.” → Reassure that trichotillomania is a psychiatric disorder, not intentional misbehavior. It is often triggered by stress or anxiety. Encourage the family to support the patient, avoid blame, and engage in therapy. Emphasize that the condition is treatable with appropriate psychiatric care.
📘 Nelson's Textbook of Pediatrics – Chapter 380.2: Bezoars (Core Summary)
📖 Definition
Bezoar = accumulation of exogenous matter in the gastrointestinal tract (stomach, intestine).
Bezoar = accumulation of exogenous matter in the gastrointestinal tract (stomach, intestine).
📊 Types
Phytobezoar (most common), trichobezoar (hair), lactobezoar (infants), pharmacobezoar, and Rapunzel syndrome (trichobezoar with tail).
Phytobezoar (most common), trichobezoar (hair), lactobezoar (infants), pharmacobezoar, and Rapunzel syndrome (trichobezoar with tail).
🩺 Trichobezoar
Associated with trichotillomania (hair pulling) and trichophagia (hair eating). Often in adolescent females.
Associated with trichotillomania (hair pulling) and trichophagia (hair eating). Often in adolescent females.
📝 Clinical features
Vomiting, abdominal pain, weight loss, early satiety, epigastric mass, halitosis, alopecia, iron deficiency anemia.
Vomiting, abdominal pain, weight loss, early satiety, epigastric mass, halitosis, alopecia, iron deficiency anemia.
🔬 Diagnosis
Barium study (filling defect, trapped contrast), CT, upper endoscopy. Barium study shows 'moth‑eaten' appearance.
Barium study (filling defect, trapped contrast), CT, upper endoscopy. Barium study shows 'moth‑eaten' appearance.
💊 Management (small)
Endoscopic removal, fragmentation. Coca‑Cola for phytobezoars (not hair).
Endoscopic removal, fragmentation. Coca‑Cola for phytobezoars (not hair).
💊 Management (large)
Surgical gastrotomy (or laparoscopy) for large trichobezoars. Rapunzel syndrome requires surgery to remove the tail.
Surgical gastrotomy (or laparoscopy) for large trichobezoars. Rapunzel syndrome requires surgery to remove the tail.
🧠 Psychiatric
Address underlying trichotillomania with CBT (habit reversal), SSRIs. Recurrence high without psychiatric treatment.
Address underlying trichotillomania with CBT (habit reversal), SSRIs. Recurrence high without psychiatric treatment.
📈 Prognosis
Excellent for bezoar removal; recurrence depends on psychiatric management.
Excellent for bezoar removal; recurrence depends on psychiatric management.
📖 Nelson's Textbook Reference (22nd Edition, Chapter 380.2):
“Trichobezoars are composed of hair and are almost always associated with trichotillomania and trichophagia. They present with abdominal pain, vomiting, weight loss, and a palpable epigastric mass. A barium study shows a filling defect with barium trapped in the interstices. When the bezoar extends into the small intestine, it is termed Rapunzel syndrome. Treatment is endoscopic removal for small bezoars, but large trichobezoars require surgical removal via gastrotomy. Psychiatric referral is essential to prevent recurrence.”
“Trichobezoars are composed of hair and are almost always associated with trichotillomania and trichophagia. They present with abdominal pain, vomiting, weight loss, and a palpable epigastric mass. A barium study shows a filling defect with barium trapped in the interstices. When the bezoar extends into the small intestine, it is termed Rapunzel syndrome. Treatment is endoscopic removal for small bezoars, but large trichobezoars require surgical removal via gastrotomy. Psychiatric referral is essential to prevent recurrence.”
⭐ TOACS TAKE‑HOME POINTS (Bezoars – Nelson 380.2):
1. Trichobezoar = hair ball in stomach, usually in adolescent girls with trichotillomania.
2. Rapunzel syndrome = trichobezoar with a tail extending into the duodenum/jejunum.
3. Classic presentation: vomiting, weight loss, epigastric mass, halitosis.
4. Barium study shows filling defect with trapped contrast (moth‑eaten appearance).
5. Diagnosis: confirmed by endoscopy or CT.
6. Small bezoars: endoscopic removal.
7. Large bezoars / Rapunzel: surgical gastrotomy (with possible enterotomy for tail).
8. Psychiatric referral is essential (CBT, habit reversal, SSRIs).
9. Recurrence is high if underlying trichotillomania is not treated.
10. Phytobezoars (vegetable/fruit) may be treated with Coca‑Cola, but trichobezoars do not dissolve and need mechanical removal.
1. Trichobezoar = hair ball in stomach, usually in adolescent girls with trichotillomania.
2. Rapunzel syndrome = trichobezoar with a tail extending into the duodenum/jejunum.
3. Classic presentation: vomiting, weight loss, epigastric mass, halitosis.
4. Barium study shows filling defect with trapped contrast (moth‑eaten appearance).
5. Diagnosis: confirmed by endoscopy or CT.
6. Small bezoars: endoscopic removal.
7. Large bezoars / Rapunzel: surgical gastrotomy (with possible enterotomy for tail).
8. Psychiatric referral is essential (CBT, habit reversal, SSRIs).
9. Recurrence is high if underlying trichotillomania is not treated.
10. Phytobezoars (vegetable/fruit) may be treated with Coca‑Cola, but trichobezoars do not dissolve and need mechanical removal.
🔗 Additional resources:
• Paeds.online – FCPS Paediatrics TOACS station library
• Trichotillomania Learning Center – resources for patients and families
• Paeds.online – FCPS Paediatrics TOACS station library
• Trichotillomania Learning Center – resources for patients and families