Trichobezoars in pediatric surgery: a narrative review of clinical perspectives, surgical strategies, and psychological considerations

Introduction

Background

Bezoars are accumulations of undigested material forming mass-like structures within the digestive tract V体育官网入口. Although they primarily occur in the stomach, they can be found anywhere from the oesophagus to the rectum.

The term “bezoar” comes from the Persian “panzehr” and Arabic “badzehr”, both meaning “antidote” VSports在线直播. Until the 18th century, they were believed to have magical properties and were used as antidotes and talismans (1-3).

There are four main types of bezoars (4): phytobezoars, composed of plant fibers and tannins; trichobezoars, made up of hair and fibers, commonly linked to trichotillomania and trichophagia; lactobezoars, occurring in newborns due to milk concretions; and pharmacobezoars, resulting from medication ingestion. Other reported causes include antacids (5), candy, chewing gum (6,7) and paper (8) V体育2025版. Trichobezoars are relatively rare, accounting for approximately 6% of all bezoars.

They typically result from the repeated ingestion of hair (trichophagia), often linked to underlying psychiatric disorders such as trichotillomania. Since hair is resistant to digestion and gastric motility, it accumulates over time and may eventually form large, obstructive gastric masses VSports.

Rationale and knowledge gap

Although rare, pediatric trichobezoars present unique challenges that differ from those observed in adults VSports app下载. Children may have more subtle or delayed symptoms, and the psychological profile often necessitates a different diagnostic and therapeutic approach. In addition, there is currently no consensus on optimal management—particularly regarding the role of endoscopic removal versus surgery, and how to effectively prevent recurrence.

Psychological factors are central to this condition. Most pediatric patients with trichobezoars suffer from underlying psychiatric disorders such as trichotillomania and trichophagia. Ignoring these comorbidities increases the risk of recurrence, even after technically successful surgical treatment. Therefore, understanding the psychological dimension is essential for effective and lasting care V体育官网.

Objective (V体育ios版)

This article aims to synthesize current data on the diagnosis, management, and psychiatric aspects of trichobezoars in children. We present this article in accordance with the Narrative Review reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-41/rc).

Methods (VSports)

We searched for papers published without time restrictions on PubMed, Scopus, and Web of Science databases in November 2023, using the title and abstract keywords “trichobezoar”, “Rapunzel syndrome”, “gastric bezoars”, “surgical management of bezoars”, “endoscopic removal of bezoars”, and “trichotillomania”. Studies published in English and French were included in our review. Case reports, case series, retrospective and prospective cohort studies, systematic reviews, and meta-analyses discussing epidemiology, pathophysiology, clinical presentation, diagnosis, and management of trichobezoars were selected. Non-human studies, studies on other types of bezoars without mention of trichobezoars, and articles lacking sufficient clinical data were excluded. Additional references were identified through citation tracking of key articles. The selection of references was agreed upon by two independent reviewers, with disagreements resolved through discussion or consultation with a third reviewer. The search strategy is summarized in Table 1.

Pathophysiology (V体育平台登录)

In adults, bezoar formation is associated with conditions such as cystic fibrosis, diabetes, hypothyroidism, renal failure, and gastric motility disorders (7). Psychiatric disorders, particularly in patients with gastroparesis or a history of gastric surgery (resections, bypass, bariatric procedures), also increase susceptibility (9).

In children, bezoars are often linked to pica, a condition characterized by ingestion of non-nutritive substances (10). Trichobezoars are more frequent in adolescent females with trichotillomania, a compulsive hair-pulling disorder often concealed due to fear of parental reprimand, leading to trichophagia, pulled hair ingestion (11).

Once ingested, hair and fibers become trapped within the gastric folds, disrupting normal peristalsis. Lipid and mucus deposits contribute to the formation of a smooth, glistening mass, often causing halitosis. Gastric acid exposure denatures the hair, giving it a blackish color regardless of its original shade (12). Over time, the mass molds to the shape of the stomach (Figure 1) and may extend beyond the pylorus into the duodenum or small intestine (13), leading to Rapunzel syndrome, first described by Vaughan in 1968 (14). This can cause intestinal obstruction, intussusception, pancreatitis, or cholestatic jaundice due to ampullary obstruction. Detached fragments may migrate distally, resulting in small bowel obstruction.

Figure 1 Trichobezoar resembling the shape and contours of the stomach.

V体育官网入口 - Epidemiology

Trichobezoars predominantly affect the pediatric population, with up to 90% of cases occurring in females younger than 20 years (15). However, rare cases in younger children and males have also been described, suggesting the need for high clinical suspicion across age and gender groups (10).

Clinical presentation and complications

Trichobezoars are diagnosed incidentally, through classic symptoms, or after complications arise—especially in Rapunzel syndrome cases. They can be mistaken for tuberculosis (16) or cancer.

Initially, trichobezoars may be asymptomatic. Over time, they can cause abdominal pain, distension, intermittent constipation, and vomiting (17). If left undiagnosed, they may lead to severe malnutrition, early satiety, weight loss, and fatigue (18-20). Halitosis is a common finding, often indicative of gastric content decomposition. Some patients may also pass hair in their stools (16).

On physical examination, a firm, non-tender epigastric mass is frequently detected. While not always present, alopecia or hair thinning should raise suspicion (21). A history of trichophagia is a crucial diagnostic clue, particularly in adolescent females (11). Additionally, some reports link trichobezoars to autism spectrum disorder (22,23).

Trichobezoars are strongly associated with psychiatric disorders, particularly trichotillomania and trichophagia. Trichotillomania is typically divided into two subtypes: the focused type, where hair-pulling is a conscious response to stress, and the automatic type, which occurs unconsciously (24). Many children diagnosed with trichobezoars also exhibit other psychological conditions, such as pica, attention deficit hyperactivity disorder (25), intellectual disabilities (26), or a history of emotional trauma (27). These overlapping disorders complicate diagnosis and emphasize the need for thorough psychiatric evaluation. Moreover, neurobiological studies suggest dysregulation in corticostriatal circuits in patients with trichotillomania, providing a rationale for integrating both behavioral and pharmacological interventions (28).

Complications can be serious in Rapunzel syndrome, where the trichobezoar extends past the pylorus and causes intestinal blockage, bilious vomiting, and absence of stool or gas (29). Gastric perforation, though rare, may present as an acute abdomen (30) but can also remain asymptomatic if it occurs in the posterior stomach wall, isolated by the bezoar mass (31). Other reported complications include intussusception due to migrating bezoar fragments (32,33), gastrointestinal bleeding from pressure-induced mucosal ulceration (34), and dysphagia when the bezoar obstructs the gastroesophageal junction (35). Bezoars extending into the duodenum can also cause pancreatitis (36-38) or jaundice (39) by obstructing the ampulla of Vater. Metabolic disturbances related to malnutrition may lead to electrolyte imbalances and neurological symptoms such as seizures or encephalopathy (16). Additionally, rare cases of generalized edema (40), amenorrhea, and cerebral venous thrombosis have been reported in the literature (19).

Diagnostic workup

The diagnosis of trichobezoars requires a thorough clinical evaluation supported by imaging and laboratory investigations.

Traditionally, bezoars were identified on plain radiographs as a mottled intragastric mass conforming to the stomach’s contours, with a radiolucent rim and possible displacement of the transverse colon. A speckled gas pattern or an intragastric filling defect may also be seen. However, plain radiographs alone diagnose only 18% of cases, limiting their reliability (41).

Contrast-enhanced upper abdominal radiographs confirm that a mobile irregular, coherent intraluminal mass is present. The mass is best visualized on delayed films after most of the barium has left the stomach or following the introduction of air into the stomach to produce a double contrast effect (41). Calcified tumors and fecalomas, which can sometimes mimic the appearance of trichobezoars, are also easily recognizable on a plain abdominal radiograph (41,42).

Ultrasound, frequently the first-line imaging modality due to its accessibility and safety, typically shows a well-defined hyperechoic mass with posterior acoustic shadowing. Point-of-care ultrasound (POCUS) has proven useful for rapid diagnosis (43), distinguishing trichobezoars from food-filled stomachs via a clear, intense acoustic shadow behind an anterior band of echogenicity (44). In some cases, a ‘twinkling’ artifact may also be observed, as noted in one case from a multicenter series on pediatric trichobezoars, caused by the rough surface of tightly packed hair (45). Additionally, ultrasound aids in differentiating trichobezoars from other epigastric masses, such as pancreatic pseudocysts, neuroblastomas, or gastric duplications, which have distinct sonographic appearances.

However, computed tomography (CT) remains the gold standard for diagnosing trichobezoars (31). As first described by Newman in 1988 (44), the characteristic CT appearance is an intragastric mass made of compressed concentric rings with entrapped air and debris (46) (Figure 2). CT also helps determine the extension of the bezoar into the duodenum (Rapunzel syndrome), locate any detached fragments that may have migrated into the small intestine, and assess for complications such as reactive gastritis (manifested as wall thickening with mucosal enhancement), obstruction, perforation, or intussusception (47).

Figure 2 Contrast-enhanced CT scans showing a large trichobezoar filling the stomach and extending into the intestines, resembling the gastric contours. (A-D) Axial views demonstrating the well-defined intraluminal mass with heterogeneous density. (E,F) Coronal and sagittal views highlighting the trichobezoar’s cast-like shape conforming to the stomach’s anatomy. CT, computed tomography.

Upper gastrointestinal endoscopy serves as both a diagnostic and therapeutic tool. It allows direct visualization of the trichobezoar, confirming its size and consistency. Endoscopy is particularly useful when other imaging modalities yield inconclusive results or when small bezoars are suspected.

Laboratory studies may reveal anemia (48), electrolyte imbalances, or hypoalbuminemia due to malnutrition or chronic blood loss (18), particularly in complicated cases. Indeed, iron deficiency anemia may arise from occult gastrointestinal bleeding secondary to mucosal ulceration.

"VSports在线直播" Management

Management of trichobezoar involves a combination of medical, endoscopic, and surgical approaches depending on the size, location, and severity of complications. Additionally, addressing underlying psychological disorders such as trichotillomania and trichophagia is essential to prevent recurrence.

Endoscopic management

For small trichobezoars confined to the stomach without associated complications, non-invasive strategies can be effective. Endoscopic removal is the preferred first-line treatment because enzymatic dissolution [e.g., papain, cellulase, or Coca-Cola (49,50)], effective in other bezoars, is ineffective against hair due to its resilient structure. Endoscopic removal is also possible for trichobezoars with an elongated shape, with intravenous glucagon administration facilitating relaxation of the lower oesophageal sphincter, as described by Saeed et al. (51). Larger trichobezoars, however, often require fragmentation for complete extraction. Tools such as biopsy forceps, snares, endoscopic scissors (52), and variceal ligator caps (53) have been employed with mixed results. Other fragmentation methods, such as lasers, water jets (54), and extracorporeal shock-wave lithotripsy have also been investigated but proven ineffective (55). Electrical devices may be considered as alternatives. However, these tools may cause mucosal injury or perforation, particularly when synthetic fibers release hydrogen chloride (56).

While early studies reported success rates as low as 5% (38), advancements in endoscopic techniques have led to improved outcomes, with success rates now reaching approximately 30% (56). However, the therapeutic efficacy of endoscopy remains largely confined to smaller trichobezoars. Larger masses tend to be refractory to endoscopic extraction due to their size, density, and the difficulty of achieving complete fragmentation and removal. Moreover, endoscopic fragmentation may lead to distal migration of bezoar fragments, potentially resulting in small-bowel obstruction (57).

Surgical management (VSports)

Surgical treatment remains the most effective and definitive approach. The optimal approach for trichobezoar removal remains controversial. While laparotomy remains the gold standard for large or complicated trichobezoars (58), laparoscopy offers significant advantages in terms of recovery and postoperative outcomes, particularly in less complicated cases.

Laparotomy with gastrotomy provides direct access to the bezoar and facilitates complete removal, including any fragments in the intestines. However, it is associated with greater postoperative morbidity, including pain, prolonged hospitalization, and infection risks. To mitigate these risks, some surgeons advocate for wound protectors (59) or seromuscular suturing of the stomach to the skin incision (60).

Since Nirasawa’s (61) first laparoscopic trichobezoar extraction in 1998, various refinements have been reported to optimize the procedure. Laparoscopic removal poses two main challenges: minimizing contamination during stomach access and avoiding a large incision that negates the benefits of minimally invasive surgery.

Early techniques for trichobezoar access, such as Nirasawa’s (61), involved a large anterior gastrotomy, increasing the risk of peritoneal contamination. To mitigate this, Ulukent (62) proposed enclosing the bezoar in an endobag inside the stomach before extraction. Dorn (63) introduced a laparoscopic method using a small gastrotomy with a blunt trocar, deploying a gastric balloon to stabilize the intragastric port, followed by carbon dioxide insufflation and fragmentation via a working trocar. Kanetaka et al. (64) described a combined laparoscopic-endoscopic approach, using a mini-laparotomy in the epigastric region for gastrotomy and inserting a 5 mm laparoscopic port for fragmentation with laparoscopic scissors. Filipi (65) proposed an alternative using two modified percutaneous endoscopic gastrostomy (PEG) ports for laparoscopic fragmentation. Though these approaches avoid large incisions, they remain technically demanding and time-consuming. Song et al. (66) emphasized the difficulty of fragmenting large or dense bezoars with laparoscopic scissors.

Once freed, trichobezoar extraction remains technically challenging. Various methods have been proposed, including suprapubic incisions, mini-laparotomy extensions via the left lower quadrant trocar incision, and upper midline incisions (61,67,68). While these approaches allow for intact removal, they are associated with an increased risk of wound infection (67). To minimize complications, Cintolo et al. and Fraser et al. (69,70) suggested extracting the bezoar in a controlled manner by bringing the extraction bag’s neck through a trocar incision for piecemeal removal. Similarly, Dorne (63) utilized a working scope to extract fragments. For exclusively intragastric fragmentation, Kanetaka and Filipi favored endoscopic removal (64,65).

Each surgical technique used in the treatment of trichobezoars has its own advantages and limitations (Table 2). The choice of surgical approach should be guided by the size and location of the bezoar, the presence of complications, and the surgeon’s expertise. While both laparotomy and laparoscopy are viable options for non-complicated cases, it is essential to exercise caution when considering a minimally invasive approach. Laparoscopy may be suitable for selected patients with small to moderate bezoars, but its application is generally limited in cases of large trichobezoars that require significant traction for removal. In such scenarios, the laparoscopic technique carries a higher risk of peritoneal contamination, prolonged operative time, and conversion to open surgery, potentially negating its minimally invasive benefits. Therefore, when the bezoar extends beyond the pylorus or is associated with complications, laparotomy remains the preferred approach to ensure safe and complete extraction.

Some authors advocate for a temporary gastrostomy tube (7–10 days) to facilitate gastric decompression and restore normal peristalsis, particularly in cases of prolonged gastric distension (31).

Psychiatric interventions

Psychiatric intervention is essential in the management of trichobezoars, not only to prevent recurrence but to address underlying psychiatric conditions. Cognitive-behavioral therapy (CBT), particularly habit reversal training (HRT), remains the most evidence-based first-line intervention (10,71). HRT assists patients in identifying triggers and adopting alternative behaviors. Also, new technologies, such as wearable behavioral devices that detect hand movement toward the scalp, have shown promise in supporting HRT adherence in children (72). Emerging modalities, such as dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT), have shown efficacy in patients with comorbid emotional dysregulation and obsessive-compulsive features (73). Despite these advancements, relapse remains common, especially when follow-up is unstructured or prematurely discontinued. Relapse rates may reach 50–67% in the absence of ongoing psychiatric support (73,74).

Pharmacological options, such as selective serotonin reuptake inhibitors (SSRIs), glutamate modulators, and atypical antipsychotics, may be beneficial in moderate to severe cases. Notably, N-acetylcysteine (NAC) has shown promise in adults with trichotillomania and has good tolerability in pediatric patients, though its efficacy may be limited in those with automatic hair-pulling behaviors (72). However, the role of medication remains controversial in pediatric populations, with limited and variable evidence (28,72). Some patients may require combined or sequential therapies to achieve lasting results.

Recurrence after surgery is frequently reported in the absence of psychiatric care, emphasizing the need for multidisciplinary management. Ideal care involves pediatric surgeons, psychiatrists, pediatricians, child psychologists, and, when possible, school-based counselors to ensure behavioral continuity in everyday environments (27). Parental education and involvement are essential in monitoring signs of relapse, promoting adherence to treatment, and reducing stigma (75). A minimum psychiatric follow-up of 12 months postoperatively is recommended to optimize long-term outcomes (73).

Limitations

This review is limited by the predominance of case reports and small case series in the available literature, which may reduce generalizability. Future prospective studies comparing surgical techniques and psychiatric interventions are needed.

Conclusions (V体育平台登录)

Trichobezoars present significant challenges in pediatric surgery, with ongoing controversies regarding the optimal surgical approach. Although laparotomy remains the gold standard for large or complicated cases, laparoscopic and hybrid techniques provide minimally invasive alternatives. However, their efficacy remains debated due to technical challenges. The high recurrence rate due to underlying psychiatric disorders highlights the need for a multidisciplinary approach. Future research should focus on comparative studies of surgical techniques, advancements in minimally invasive removal methods, long-term psychiatric management strategies, and early screening tools to prevent recurrence and improve patient outcomes.

"VSports最新版本" Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-41/rc

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-41/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-41/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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