Nursing Care Given to a Child Diagnosed with Gastric Trichobezoar Developed Outside Rapunzel Syndrome: A Case Report Volume 62- Issue 2

Pınar GÖV¹*, Beşir Çakır² and Hatice Köseoğlu³

• ¹Assistant Professor, Gaziantep University Faculty of Health Sciences, Nursing Department, Turkey
• ²Research Assistant, Gaziantep Islam Science and Technology University, Faculty of Health Sciences, Nursing Department, Turkey
• ³Student Nurse, Gaziantep University, Faculty of Health Sciences, Department of Nursing, Turkey

Received: May 30, 2025; Published: June 05, 2025

*Corresponding author: Pınar GÖV, Assistant Professor, Gaziantep University Faculty of Health Sciences, Nursing Department, Gaziantep, Turkey

DOI: 10.26717/BJSTR.2025.62.009707

Abstract PDF

Bezoar is a rare paediatric disease characterised by the accumulation of substances such as hair, pharmacological drugs and residual fruit and vegetable fibres in the gastrointestinal tract. There are many types of bezoars: trichobezoar, pharmacobezoar, lactobezoar and phytobezoar. This study was conducted to carry out a case report of the nursing care of a pediatric patient diagnosed with gastric trichobezoar that developed outside of Rapunzel syndrome. The case is an 11-year-old girl. He applied to the emergency room with complaints of nausea, abdominal swelling, pain and tenderness. In the radiological examination of the case, the stomach appeared distended, and later, endoscopy was performed and the patient was diagnosed with gastric trichobezoar. Surgical removal of the detected gastric trichobezoar was planned and a surgical program was implemented. R0 dietary restriction was applied to the patient in the pre-operative and post-operative periods, and gastric lavage was performed with an NG catheter in the post-operative period and a pharmacological treatment program was applied. The nursing process of the case was planned and carried out based on NANDA nursing diagnoses in the pre-operative and post-operative periods. As a result, in this case report, a nursing care plan specific to a pediatric case diagnosed with gastric trichobezoar other than Rapunzel syndrome was formed.

Keywords: Bezoar; Trichobezoar; Pediatric surgery; Nursing

Bezoars are defined as pathologies that cause the accumulation of hair, undigested food particles and pharmacological substances in the gastrointestinal tract (Nour, et al. [1]). The condition known as gastric trichobezoar is characterised by indigestion of ingested food and accumulation of hair in the stomach (Nita, et al. [2]). The development of gastric trichobezoars is primarily influenced by two key factors: trichotillomania, characterised by the act of hair plucking in children, and trichophagia, defined as the swallowing of plucked hair (Jidane, et al. [3]). Within the category of bezoars, trichobezoars represent the most common form in the paediatric field and are more prevalent in adolescent girls (Nour, et al. [1,4]). The incidence of gastric trichobezoars in paediatric diseases is among the rare diseases with a prevalence of less than 1% (Habib, et al. [5]). The manifestation of bezoars, typified by the abandoning behaviour, is frequently associated with Rapunzel syndrome. Hair-eating disease, otherwise referred to as Rapunzel syndrome, is a condition that is frequently observed in girls (Wyllie [6]). Gastric trichobezoars manifest as a tail-shaped protrusion extending into the small intestine, thus justifying their nomenclature. The nomenclature of the syndrome has been likened to that of a princess in a Brothers Grimm fairy tale, who was subjected to surgical intervention due to an obstruction in the gastric outlet, and who utilised her long hair as a means of escape from the tower in which she was imprisoned (Sacco et al., 2024). The ingestion of hair has been demonstrated to induce a series of significant physiological responses, encompassing symptoms such as nausea, vomiting, weight loss and ileus. Although trichobezoars are typically found in the stomach, some components can extend into the duodenum, ileum, jejunum and colon (Duke, et al. [7]). The deposits responsible for bezoars, in conjunction with the mucosal inflammation that accompanies these deposits, result in symptoms of the disease that are non-specific (Yankov, et al. [8]). Whilst the diagnosis of bezoars is typically made by imaging methods, delays may be experienced in cases where there is an absence of disease-specific symptoms (Ali, et al. [9,10]). Furthermore, the fact that trichobezoars have many significant complications, such as mucosal deformities developing in the gastric tissue and obstruction of the gastric canal, reveals the necessity to prevent or treat the disease (Belhadj, et al. [11]). The present study was conducted with the objective of presenting the nursing care given to a paediatric case diagnosed with gastric trichobezoar that developed outside Rapunzel syndrome.

An 11-year-old girl presented to the hospital’s emergency department with complaints of abdominal distension and tenderness, nausea and vomiting. Her weight was documented as 26 kg (below 3 percent) and her height as 145 cm (between the 10th and 25th percentiles). It is the contention of the parents that no chronic diseases other than anaemia were revealed in the subject’s medical history. However, it was reported that he exhibited hair-eating behaviour from an early age. The patient’s hair-eating behaviour, which manifested during preschool, remained unrecorded until the manifestation of a pathological symptom, at which point he was admitted to hospital. The patient exhibited symptoms including abdominal swelling and tenderness, anorexia, indefinite weight loss, restlessness, recurrent episodes of nausea and vomiting, withdrawal and an inability to speak. These symptoms are consistent with those observed in the later stages of Rapunzel syndrome. The patient exhibited a marked reluctance to engage in dialogue with healthcare professionals. Consequently, communication regarding the patient’s clinical condition and prognosis was facilitated by the involvement of the parents. The patient had no history of consanguinity, pets, woollen pillows or duvets, or allergic reactions. The patient exhibited no prior medical history of hospitalisation, diarrhoea or constipation.

Physical Examination

A physical examination was conducted, but no organomegaly in the abdomen was detected. A detailed examination of the head and neck region was conducted, but no abnormalities were detected. However, auscultation of the lungs revealed no rales and a rhythmic murmur in the heart. The strength and tone of the cranial nerves and muscles were found to be within normal parameters.

Radiological Examination

A radiological examination of the patient was performed using Computed Tomography (CT) scans of the upper abdomen and pelvis. A detailed radiological evaluation of the patient revealed that the liver, bile duct, bilateral adrenal glands, pancreas and kidneys were in normal position and size. No pathological findings were detected. However, the stomach was reported to have a distended appearance, and it was deemed appropriate to examine the patient in a paediatric gastroenterology consultation for further examination by paediatric endoscopy. In conclusion, following paediatric endoscopy, a bezoar deposit was detected in the stomach of the patient and thus the case was diagnosed as gastric trichobezoar. Furthermore, the surgical removal of the bezoar deposit was recommended, and the patient was admitted to the paediatric surgery service. A consultation with a child psychiatrist was also requested, due to the suspicion that the bezoar accumulation was related to Rapunzel syndrome.

Psychological Examination

A consultation in the domain of child and adolescent mental health was requested following the detection of bezoars, which were identified as a psychopathological condition characterised by hair eating and multiple stress factors, a consequence of Rapunzel syndrome. Consequently, the psychological evaluation failed to identify any stress factors, thereby ruling out the possibility of an association between bezoar accumulation and Rapunzel syndrome. In conclusion, the patient was diagnosed with a gastric trichobezoar, a rare condition that develops independently of Rapunzel syndrome.

Laboratory Findings

In the laboratory findings of the patient, white blood cell (WBC) amount was 7.2, neutrophil percentage (NE%) was 50.3, lymphocyte percentage (LY%) was 32.9, monocyte percentage (MO%) was 13.9, eosinophil percentage (EO%) was 2.2, basophil percentage (BA%) was 0.7, Red Blood Cells amount (RBC) was 4.44, haemoglobin (HGB) level was 12.2, haematocrit (HCT) was 37.2, Mean Corpuscular Volume (MCV) 83.8, mean corpuscular haemoglobin (MCH) 27.5, Mean Corpuscular Haemoglobin Concentration (MCHC) 32.8, Red cell distribution width (RDW) 12.9, platelet (PLT) 429, Mean platelet volume (MPV) 9.7, procalcitonin (PCT) 0.42, Platelet Distribution Width (PDW) 10.2, Red Cell Distribution Width - Standard Deviation (RDWSD) 39.2, Anti-HCV: 0.09, Anti-HBC IgM: 0.12, Anti-HBS: 4.71.

Surgical and Pharmacological Treatment

The patient’s treatment programme was planned as a surgical intervention and the bezoar was surgically removed. A thorough evaluation of the surgically removed bezoar accumulation revealed that it covered a significant portion of the stomach and gastric duct. In the postoperative period, the patient was placed on R0 diet due to dizziness and nausea. Gastric lavage was performed at regular intervals via nasogastric catheter. Pharmacological treatment programme consisted of 500cc Isodex (3*1), paracetamol (4*1), Ceftriaxone (2*1) and Flagy (3*260mg).

Nursing Care

The patient underwent a series of surgical preparations in the preoperative period. Postoperative care was provided by the nursing team and the patient was subjected to R0 diet restriction for approximately 20 hours. The patient’s vital signs, recorded prior to surgery, revealed a pulse rate of 80 beats per minute and a SpO2 level of: 97% in the preoperative period and pulse rate: 98 SPO2: In the postoperative period, the success rate was 95%. The patient’s care was conducted in accordance with the nursing diagnosis system established by the North American Nursing Diagnoses Association (NANDA) (Figure 1). In this particular case, the patient, who had been diagnosed with multiple nursing diagnoses, was discharged following the administration of nursing care and pharmacological treatment. The diagnoses made during the care of the patient are given in Table 1.

Figure 1

Table 1: Nursing care plan of the case.

Trichotillomania and trichophagy are defined as a behaviour characterised by uncontrollable impulses (American Psychiatric Association [12]). It is most commonly observed among adolescents, especially female adolescents (American Psychiatric Association [12]). The fact that this case was also in the adolescent age group and female gender further supports the view in the literature. The repeated occurrence of trichotillomania and trichophagia behaviours results in the formation of indigestible bodies known as bezoars. Bezoars are defined as masses that result from the accumulation of various structures, including to hair, nails, and indigestible plant fibres (Kırkıl, et al. [13]). Although bezoars can be observed in the small and large intestines, they are usually found in the stomach (Tatar, et al. [14]). In this case, a gastric trichobezoar was diagnosed, and it was found that the bezoar covered the entire gastric line. The majority of trichobezoars are diagnosed at a late stage, as the disease is typically asymptomatic in the early stages and manifests itself in the late stages (Gorter, et al. [15]). In this particular instance, the scenario was analogous, with the patient exhibiting trichotillomania and trichophagia from preschool to adolescence. However, the diagnosis of bezoar was made at the age of 11 years, following an emergency presentation. Cases often complain of symptoms such as anorexia, unspecified weight loss, alopecia, vitamin and mineral deficiency, recurrent nausea, vomiting and pain (Kırkıl, et al. [13,16]). This was the case in this case; the patient presented to the emergency department with recurrent nausea, vomiting and severe abdominal discomfort and pain. In addition, the examination revealed that the patient had low percentile weight and weight and fluid volume deficiency. Furthermore, trichobezoars have been observed to cause iron deficiency anaemia due to malabsorption (Gonuguntla, et al. [17]). The observation of iron deficiency anaemia in this case supports the prevailing view in the literature. Trichobezoars have been known to persist in the stomach for extended periods, often assuming the shape of the stomach itself over time (Zamir, et al. [18]). In this case, it was observed that the trichobezoars assumed a stomach-like configuration post-operatively. Numerous removal procedures are available for the treatment of gastric trichozoars, including endoscopic and laparoscopic techniques (Sharma, et al. [19]). In this case, treatment was planned and performed by surgical laparoscopy, which involved removal of the bezoar by a surgical procedure. Patients diagnosed with trichobezoars are frequently associated with Rapunzel syndrome, and it is common for a consultation with a psychiatrist to be requested (Hatiboğlu, et al. [20]). In this particular instance, a child-adolescent mental health psychiatry examination was conducted, and the diagnosis of trichobezoar was associated with Rapunzel syndrome. However, children diagnosed with gastric trichobezoar, defined as a rare disorder without an underlying psychiatric condition, should be carefully monitored during and after treatment (Saraç, et al. [21]). In this case, the care provided was within the framework of the NANDA nursing diagnoses and the desired outcomes were achieved in most of the diagnoses. In addition, it was aimed to integrate the care into the post-discharge period with the education given to the patient and parents.

The necessary interventions and information were provided within the framework of the nursing care and process offered to the paediatric case in the case presentation and in accordance with the nursing diagnoses. The procedures to be performed by the case and the parents in the post-operative period, the correct and effective provision of the familial process, regular follow-up of the factors causing the diagnosis and the growth and development of the case, and the importance of post-discharge treatment were mentioned. The implementation of nursing care for the patient resulted in a reduction in the discharge process and compliance with treatment, as well as a decline in existing negative factors. Bezoar is an uncommon condition that necessitates early diagnosis and treatment. As the disease disrupts the child’s nutritional patterns, it also has a detrimental effect on their growth and development. Consequently, it is imperative that parents are educated on the subject of bezoar disease, that children diagnosed with the condition receive an effective and appropriate care process, and that patients and parents are informed of the measures to be taken to prevent the recurrence of the disease following discharge.

1. Islam Nour, Mona Abd Alatef, Ahmed Megahed, Sohier Yahia, Yahya Wahba, et al. (2019) Rapunzel syndrome (gastric trichobezoar), a rare presentation with generalised oedema: case report and review of the literature. Paediatrics and International Child Health 39(1): 76-78.
2. Andreia F Niţă, Chris J Hill, Richard M Lindley, Sean S Marven, Mike A Thomson (2020) Human and doll's hair in a gastric trichobezoar, endoscopic retrieval hazards. Journal of Pediatric Gastroenterology and Nutrition 71(2): 163-170.
3. Jidane S, Belgassi K, Belkouch A, Zidouh S, Belyamani L (2023) Huge gastric trichobezoar in school-aged girl: A Case Report. J Med Case Rep Case Series 4(06).
4. Khirallah MG, El-Dessouki NI, Kurdi M (2022) Laparoscopic management of gastric trichobezoar in children: a case series study. Journal of Pediatric Endoscopic Surgery 4(2): 63-67.
5. Murad Habib, Muhammad Bin Amjad, Muhammad Abbas, Muhammad Amjad Chaudhary (2022) Gastric Trichobezoars in paediatric population–A series of six cases and literature review. Annals of Medicine and Surgery 84: 104906.
6. Wyllie R (2004) Foreign Bodies and Bezoars. In Behrman RE, Kliegman RM, eds. Nelson Textbook Of Pediatrics.Philadelphia:WB Saunders, pp. 1244-1246.
7. Danny C Duke, Mary L Keeley, Gary R Geffken, Eric A Storch (2010) Trichotillomania: a current review. Clinical psychology review 30(2): 181-193.
8. Yankov I, Tashev V, Kozev P, Shentova R, Mitkovski D, et al. (2022) Gastric trichobezoar in the absence of psychosocial stressors: a report of two cases. Folia Medica 64(3): 537-542.
9. Aishath Azna Ali, Rajan Gurung, Zeena Mohamed Fuad, Muaz Moosa, Isha Ali, Ahmad Abdulla , et al. (2020) Gastric trichobezoar in an end-stage renal failure and mental health disorder presented with chronic epigastric pain: a case report. Annals of Medicine and Surgery 58: 76-79.
10. Lyons D (2019) Large gastric trichobezoar causing failure to thrive and iron deficiency anaemia in an adolescent girl: a case report emphasising the imaging findings and review of the literature. BJR| case reports 5(2): 20180080.
11. Anis Belhadj, Med Dheker Touati, Mohamed Raouf Ben Othmane, Fahd Khefacha, Ahmed Saidani, et al. (2023) Revelation of Rapunzel syndrome: A rare case report of gastric trichobezoar-induced acute purulent peritonitis. International Journal of Surgery Case Reports 111: 108860.
12. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders: DSM-5. American psychiatric association.
13. Kırkıl C, Böyük A, Bülbüller N, Aygen E, Karabulut K (2011) Nadir rastlanan bir trikobezoar olgusu: Rapunzel sendromu. Gaziantep Medical Journal 17(2): 108-110.
14. Tatar C, Karşıdağ T, Özgül H, Tüzün S (2013) Gastrik Trikobezoar: Olgu Sunumu. Haseki Tıp Bülteni 51(3): 141-143.
15. R R Gorter, C M F Kneepkens, E C J L Mattens, D C Aronson, H A Heij (2010) Management of trichobezoar: case report and literature review. Pediatric surgery international 26: 457-463.
16. Comba A, Çaltepe G, Yüce Ö, Rızalar R, Kalaycı AG (2014) Karında kitlenin nadir bir nedeni: Trikobezoar. Güncel Pediatri 12(1): 51-53.
17. Gonuguntla V, Joshi DD (2009) Rapunzel syndrome: a comprehensive review of an unusual case of trichobezoar. Clinical medicine & research 7(3): 99-102.
18. Zamir D, Goldblum C, Linova L, Polychuck I, Reitblat T, et al. (2004) Phytobezoars and trichobezoars: a 10-year experience. Journal of clinical gastroenterology 38(10): 873-876.
19. Sharma D, Srivastava M, Babu R, Anand R, Rohtagi A, et al. (2010) Laparoscopic treatment of gastric bezoar. JSLS: Journal of the Society of Laparoendoscopic Surgeons 14(2): 263.
20. Hatipoğlu S, Atlıhan A, Bayramoğlu E (2015) Dev Gastrik Trikobezoar: Bir Rapunzel Sendromu Olgusu ve Literatür Derleme. Adıyaman Üniversitesi Sağlık Bilimleri Dergisi 1(1): 39-43.
21. Saraç F, Doğan G, Koyuncu A, Aydın N, Duru HNS (2020) Çok geç tanı almış bir gastrik trikobezoar olgu sunumu. Çocuk Cerrahisi Dergisi 34(2): 75-78.