Obstruction of Small Bowel Caused by Unconscious Trichotillomania: Rapunzel Syndrome

Rapunzel syndrome is a relatively rare condition in which swallowed hair masses extend to a point distal to the pylorus and cause intestinal problems. Although trichotillomania and trichophagia are secondary to psychiatric illnesses, these conditions tend to be concealed by caregivers in most pediatric cases. Rapunzel syndrome sometimes manifests as acute abdominal symptoms of unknown origin and is difficult to manage appropriately. A 14-year-old female patient was referred to our hospital due to a small bowel obstruction. Although her medical history of trichotillomania was hidden at presentation, a definitive diagnosis of Rapunzel syndrome was made based on the findings from contrast-enhanced computed tomography (CECT). The patient underwent exploratory laparotomy, and hairballs were removed via an incision of the gastric and intestinal walls. The patient recovered uneventfully and was discharged on the 11th post-operative day. Periodical psychiatric counseling is ongoing in order to prevent recurrence. Pediatric trichotillomania often progresses unconsciously, and appropriate care is necessary to prevent the development of a potentially fatal condition like Rapunzel syndrome. CECT is useful for making a definitive diagnosis of Rapunzel syndrome and determining the surgical approach. Radical laparotomy is considered to be reasonable and feasible in cases of Rapunzel syndrome, which manifests as acute abdominal symptoms.