# Recurrent Rapunzel syndrome in a young woman: Diagnostic pitfalls and surgical strategy

## TL;DR

A young woman with a history of trichobezoar surgery experienced a recurrence of Rapunzel syndrome, requiring surgery and psychiatric care to manage the condition and prevent future episodes.

## Contribution

This case highlights the recurrence of Rapunzel syndrome and emphasizes the need for multidisciplinary care, including surgical and psychiatric interventions.

## Key findings

- CT imaging was essential for diagnosing the extent of the trichobezoars in the stomach and small bowel.
- Surgical removal via laparotomy and enterotomy was effective for large, recurrent trichobezoars.
- Psychiatric follow-up is crucial to address underlying behavioral disorders and prevent recurrence.

## Abstract

Trichobezoars are typically localized to the stomach but can rarely extend into the small bowel, causing a condition known as Rapunzel syndrome. This rare entity primarily affects young females with psychiatric conditions such as trichotillomania and trichophagia. The recurrent nature of this syndrome and its association with psychological disorders necessitate a multidisciplinary approach.

A 21-year-old female presented to the emergency department with abdominal pain, nausea, and vomiting persisting for four days. On physical examination, she had diffuse abdominal tenderness and a palpable left upper quadrant mass. She had undergone surgery for a trichobezoar in 2015. CT imaging revealed a large heterogeneous intragastric mass extending into the jejunum. Surgical intervention included midline laparotomy, gastrotomy for removal of a large trichobezoar, and enterotomy to extract a second bezoar located 1.4 m from the ileocecal valve, measuring over 30 cm. The patient recovered uneventfully and was referred for psychiatric follow-up. At six months, she remained asymptomatic.

Rapunzel syndrome represents an unusual but serious gastrointestinal condition. Diagnosis is often delayed due to its non-specific presentation and rarity. CT imaging is pivotal in detecting the size, shape, and extension of trichobezoars. In this recurrent case, detailed surgical planning allowed for complete removal of both gastric and intestinal masses. Psychiatric evaluation and cognitive-behavioral therapy were initiated postoperatively to prevent recurrence. Key diagnostic challenges include delayed suspicion, misinterpretation of symptoms, and missed psychiatric associations. Surgical techniques must be adapted depending on bezoar size and location, with median laparotomy preferred for extensive disease.

Recurrent Rapunzel syndrome underscores the importance of a holistic, multidisciplinary strategy. Timely radiological diagnosis, careful surgical planning, and sustained psychiatric management are crucial for preventing recurrence. This case reinforces the need for vigilance in young females with behavioral disorders and abdominal complaints.

•Trichobezoars are rare gastric masses composed of ingested hair•Trichobezoars is Associated with psychiatric disorders like trichotillomania and trichophagia.•Rapunzel syndrome refers to a trichobezoar extending into the small bowel•CT imaging is crucial for diagnosis•Surgery remains the definitive treatment in complicated or extensive cases•endoscopy is rarely effective for large trichobezoars.•Psychiatric referral is essential to prevent recurrence

Trichobezoars are rare gastric masses composed of ingested hair

Trichobezoars is Associated with psychiatric disorders like trichotillomania and trichophagia.

Rapunzel syndrome refers to a trichobezoar extending into the small bowel

CT imaging is crucial for diagnosis

Surgery remains the definitive treatment in complicated or extensive cases

endoscopy is rarely effective for large trichobezoars.

Psychiatric referral is essential to prevent recurrence