The Rapunzel syndrome: a rare presentation of trichobezoar.

CASE HISTORY A five-year old girl was admitted in 1985 with an eight-day history of epigastric pain and vomiting. The pain was occasional and not severe. She had lost weight, to 13-1 kg, and was pale and thin. There was a tender epigastric mass. The haemoglobin concentration was 12-8 g/dl. Her mother said the child regularly pulled and ate the sleeves of her cardigans. An ultrasound scan showed a foreign body in the stomach. At laparotomy through an upper midline incision there was a large ball of wool fibre in the stomach and duodenum. There was also an interloop abscess near the jejunum due to a localised perforation. A short segment of small bowel was excised and continuity restored by end-to-end anastomosis. Mesenteric glands were noted to be enlarged. The post-operative course was uneventful. The child presented again in 1988 with a four-week history of poor appetite, lethargy and intermittent epigastric pain. Again she had lost weight, but there was no vomiting or constipation. Her mother had died four months prior to this admission. Clinically the child was thin, pale and apathetic. There was some tenderness in the epigastrium but no definite mass. The haemoglobin was 11-8 g/dl and the ESR 22 mm/hr. The barium meal (Fig 1) showed a large intragastric mass. At laparotomy a large foul -smelling mass which nearly filled the stomach was found, extending with a long string and short clumps of hair to the level of the ileocaecal valve (Fig 2). The small bowel was remarkably normal. The postoperative course was uneventful and she was eventually referred to a child psychologist.