title: Rapunzel syndrome due to ingested hair extensions: Surgical and psychiatric considerations.
abstract: BACKGROUND
  Rapunzel syndrome is a unique clinical manifestation of trichotillomania and trichophagia. The resulting gastric trichobezoar can be massive and necessitate surgical extraction.
  
  
  METHODS
  We present a case involving a 15 year-old female with a known history of trichotillomania. The patient possessed symptoms of nausea and early satiety, and admitted that she had recently consumed a large number of hair extensions. Computed tomography imaging revealed a massive gastric bezoar not amenable to endoscopic extraction. The patient underwent surgical laparotomy, and a large gastric trichobezoar was removed through an anterior gastrotomy. The trichobezoar extended past the pylorus into the duodenum, thus confirming a diagnosis of Rapunzel syndrome.
  
  
  CONCLUSIONS
  Trichobezoars formed from the consumption of hair extensions is a rare cause of Rapunzel syndrome. Surgical extraction is often necessitated due to the sheer size of the gastric bezoar that results from consuming hair extensions. If not previously established, psychiatric consultation should be pursued in the immediate post-operative course as these patients may require pharmacologic management along with behavioral therapy to avoid further episodes of trichotillomania.
  
  
  CONCLUSIONS
  This case presents a unique and modern manifestation of Rapunzel syndrome. Surgical treatment most often is required when a patient presents with a massive gastric trichobezoar. Regular post-operative psychiatric follow-up is necessary to prevent recurrent episodes.
authors.affiliation: Rowan University School of Osteopathic Medicine, Department of General Surgery, One Medical Center Drive, Stratford, NJ 08084, USA. Electronic address: devin.flaherty@jwci.org.
authors.forename: Devin C
authors.initials: DC
authors.lastname: Flaherty
authors.affiliation: Cooper University Hospital, Department of Psychiatry, Three Cooper Plaza, Suite 307, Camden, NJ 08103, USA.
authors.forename: Francis
authors.initials: F
authors.lastname: Aguilar
authors.affiliation: Cooper University Hospital, Department of Psychiatry, Three Cooper Plaza, Suite 307, Camden, NJ 08103, USA.
authors.forename: Basant
authors.initials: B
authors.lastname: Pradhan
authors.affiliation: Cooper University Hospital, Department of Pediatric Surgery, Three Cooper Plaza, Suite 403, Camden, NJ 08103, USA.
authors.forename: Harsh
authors.initials: H
authors.lastname: Grewal
keywords: Obstruction; Rapunzel syndrome; Trichobezoar; Trichophagia; Trichotillomania