Literature
Clinical Pearls & Morning Reports
Published November 20, 2024
Trichotillomania has a worldwide prevalence of 1 to 2% and is characterized by recurrent pulling out of the hair with resultant hair loss. Read the NEJM Case Records of the Massachusetts General Hospital here.
Clinical Pearls
Q: What is a “bezoar”?
A: A bezoar is a foreign body resulting from the accumulation of ingested material and is most commonly found as a hard mass in the stomach. Bezoars are classified according to their composition and include phytobezoars (composed of fruits and vegetables), trichobezoars (composed of hair), and pharmacobezoars (composed of extended-release capsules, enteric-coated aspirin, or iron). Trichobezoars are the most common bezoars in humans and are found in the stomach.
Q: Are complications related to a trichobezoar limited to gastric-outlet obstruction?
A: In rare instances, a trichobezoar extends into the small bowel — a condition called the Rapunzel syndrome. Complications of trichobezoars include obstruction, gastrointestinal bleeding due to increased pressure, perforation of the stomach or intestine, intussusception, acute pancreatitis, and cholangitis. The risk of complications is increased in patients with a trichobezoar that extends into the small bowel.
A: In patients with a bezoar, enzymatic digestion, endoscopy, and surgical laparoscopy or laparotomy are all options to consider for removal of the bezoar. In patients with a trichobezoar in particular, enzymatic digestion is not effective and the trichobezoar must be removed endoscopically or surgically. Endoscopy is less invasive and more cost-effective than surgery, but it is often not feasible owing to the shape and size of the trichobezoar. In symptomatic patients with a large trichobezoar, the trichobezoar must be removed surgically, especially if it extends into the small bowel. Laparoscopic surgery for removal of a trichobezoar is often unsuccessful because of the long operative time that is needed to remove the bezoar in pieces and because this procedure confers an increased risk of infection. Laparotomy with gastrostomy is the preferred technique for removal.
A: Trichotillomania is most commonly seen in women and girls (typically beginning in early adolescence). Anxiety and trichotillomania are distinct disorders, although anxiety commonly occurs in conjunction with trichotillomania. Obsessive–compulsive disorder, attention deficit–hyperactivity disorder, and depression are also common among patients with trichotillomania. The prevalence of trichophagia among patients with trichotillomania ranges from 5 to 20%, and among those with trichophagia, the reported prevalence of trichobezoars is approximately 1%. Given the potential serious medical consequences of trichobezoars, it is crucial to ask any patient with trichotillomania about hair ingestion. Unfortunately, trichotillomania is associated with substantial shame and embarrassment, and this commonly impedes a patient’s willingness to disclose such behaviors. When trichophagia is involved, patients with trichotillomania are even less likely to disclose this information. Thus, the first sign of a patient’s trichotillomania is likely to be the presence of a trichobezoar. Trichotillomania tends to be a chronic condition with symptoms that wax and wane over time. To date, no medications have been approved by the Food and Drug Administration for the treatment of trichotillomania; however, meta-analyses have shown a modest benefit with N-acetylcysteine — a natural supplement with antioxidant properties.