Trichobezoars one type of bezoars are concretions of swallowed hair retained within the digestive tract. Psychiatric illness and mental health problems are commonly associated with trichobezoars [8-15].

Rapunzel syndrome is a rare form of trichobezoar that extends from the stomach into the small intestine.The name Rapunzel originates from the Brothers Grimm fairy tale of a 12-year-old princess locked inside a tower, who uses her long, golden hair to permit her young prince to climb up to her window and rescue her.

The disease often affects female children and adolescents who usually have a habit of hair pulling that is called trichotillomania with resultant patchy hair loss. Trichotillomania followed by swallowing the hair (trichophagia) is one type of pica, which is defined as ‘the persistent craving and compulsive eating of non-food substances’, such as hair, sponge, soap, sand and so on 22. The case we describe did not suffer any psychiatric illnesses or hair loss and this initially made the diagnosis challenging.

Patients with a trichobezoar may be asymptomatic, which can result in late presentation and, when left chronically undiagnosed, it can lead to severe anemia through either gastrointestinal bleeding or malabsorption [6].

Clinical findings of trichobezoars differ according to the settlement site. Whereas oesophageal bezoars lead to dysphagia, reflux and retrosternal pain, gastric bezoars present with abdominal pain, nausea, vomiting, loss of appetite, weight loss, ulcerations, and perforations. Intestinal bezoars lead to partial or complete obstruction or intestinal perforation. Colonic bezoars cause abdominal pain, constipation, and obstruction at the rectosigmoid level [12].

Our case presented initially with abdominal pain and constipation for two weeks which was thought to be functional and received laxatives without any effect. This shows the importance of investigating the causes of constipation before assuming it is functional, so serious pathologies are not missed.

On examination, a mobile, well-defined mass may be palpable in the epigastrium. This may be indentable on examination, Lamberton’s sign, as quoted by O’Sullivan et al. [14]. In our case, there was soft palpable left abdominal mass which was thought to be faecal mass and after the initial ultrasound, it was suspected to be intussusception mass.

The most common complications that are reported include gastric mucosal erosion, ulceration and perforation of the stomach or small intestine, gastric outlet obstruction and intussusception.[10].

Iron-deficiency anemia is common in patients with trichobezoars, and could be the direct outcome of bleeding gastric ulcer due to pressure by massive trichobezoar [8].

Imaging is the mainstay of diagnosis and, therefore, both clinicians and radiologists need to have

a high level of suspicion to diagnose the condition early and prevent serious complications. [7] In our case the diagnosis was missed in the first setting due to lack of suspicion as it is a very rare cause for this presentation.

X-ray of the abdomen may show a radio-opaque mass in the stomach. Ultrasound reveals highly echogenic areas but is often not diagnostic 18. Our case had an x ray which showed dilated stomach without evidence of air fluid level, and ultrasound was done twice before the diagnosis was reached. On the first ultrasound scan, there was a suspicion of intussusception due to interpreting the appearance of the images as bowel in bowel. The second ultrasound scan was interpreted as normal.

Barium studies show barium in the stomach interspersed within the gastric mass. CT abdomen is often the investigation of choice in diagnosis and well-defined heterogeneous masses 9. The case we describe did not need CT abdomen as the diagnosis was strongly suspected after revisiting the clinical history and confirmed the presence of trichobezoar on contrast study. We can argue that detailed history of eating hair, linen and tissue has pointed towards the diagnosis and saved our patient unnecessary exposure to high radiation of CT abdomen.

Traditionally, a gastric trichobezoar was treated with laparotomy with either gastrotomy or enterotomy and this is still the typical treatment for large trichobezoars and Rapunzel Syndrome.

Laparotomy is the best method for treatment of trichobezoar. Retrospective study of 108 patients diagnosed with trichobezoar was performed by Gorter et al. The study concluded that the success rate of endoscopic treatment was 5%, while 75%for laparoscopic treatment. And 100% success rate was achieved by laparotomy [11]. The case we describe underwent laparotomy and gastrostomy with complete recovery.

In addition to the acute surgical treatment for a trichobezoar, psychiatric consultation is crucial to prevent relapses and to treat comorbid conditions that usually accompany this disorder [16-19]. The patient also received iron therapy for severe iron deficiency anaemia which has improved the pica.