117 Double Trouble: Rapunzel Syndrome Presenting with Closed-Loop Intestinal Obstruction Between Two Synchronous Trichobezoars

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Abstract Background Trichobezoar formation is a rare phenomenon associated with certain psychiatric conditions like trichophagia and is more frequent in young women. Rapunzel Syndrome denotes a gastric trichobezoar which extends into the duodenum. We report a rare case of dual isolated trichobezoars, a gastric and an ileal trichobezoar, causing sub-acute closed-loop intestinal obstruction between the two bezoars. Case presentation A 15-years old girl presented to the emergency department with history of generalized abdominal pain and distention for two days. She had nausea, loss of appetite, absolute constipation followed by vomiting.She was tachycardiac, had abdominal distention with an ill-defined upper abdominal mass and absent bowel sounds. CT-scan abdomen revealed a giant trichobezor in stomach tailing into duodenum and a separate small rounded mass in ileum with dilated bowel loops. Mid-line laparotomy was done. Per-operatively a giant gastric trichobezoar(22x8cms) was extracted after gastrostomy, which completely occupied the stomach and extended into the duodenum. Another large ileal trichobezoar(6x5cms) was also removed via enterotomy at 2 feet proximal to the ileo-cecal junction. Hence a markedly distended closed loop was formed between the two obstructing trichobezoars. Enterotomies were closed using vicyrl2.0. Feeding was started on post-operative day-3 & she was discharged on day-5. She developed complete wound dehiscence after 2 weeks which was surgically closed. Patient was consulted for nutritional and psychiatric evaluation and for management of trichophagia. Conclusion Trichobezoars usually present with vague abdominal symptoms and can rarely cause intestinal obstruction. Invasive intervention such as laparoscopy or laparotomy becomes necessary for such large obstructing trichobezoars. Psychiatric follow-up and management are crucial to prevent its recurrence.

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