Trichobezoar causing gastric outlet obstruction in a patient with trichotillomania

A 19‐year‐old patient with a 4‐year history of trichotillomania1 wasadmitted to our Unit for chronic abdominal pain, weight loss and non‐tender epigastric mass. Computed tomography (CT) scan showed amass occupying the entire gastric cavity and extending into the duo-denum, consistent with a bezoar (Figure 1a,b). Upper GI endoscopyconfirmed the presence of a trichobezoar2, revealing Rapunzel syn-drome. Owing to the size of the bezoar and the significant duodenalinvolvement, endoscopic treatment was excluded, and the patientunderwent a laparotomic gastrotomy with complete removal of thebezoar (Figure 1c,d). Post‐operative endoscopy confirmed successfulextraction of the foreign body and excluded ulceration due to thedecubitus of the bezoar. Additional work‐up showed a severe irondeficiency anaemia (hemoglobin 7.3 g/dL, transferrin saturation 5%and ferritin 1 ng/mL) out of proportion with the other nutritionalmarkers. Hence, suspecting a pica disorder3 in a patient with irondeficiency, further causes including coeliac disease were investigatedbut tested negative. Therefore, iron deficiency was attributed to thereduced food intake that occurred in the months preceding the hos-pital admission. At discharge, the patient was referred to the divisionof Psychiatry and no iron deficiency recurred at 26 months follow‐up.