Introduction
Trichobezoars, which are hairballs formed from ingested hair, represent a unique and often overlooked clinical entity, particularly in pediatric populations [1, 2]. These gastrointestinal obstructions are commonly associated with trichotillomania, a psychiatric disorder characterized by the compulsive pulling out of one’s hair, often accompanied by trichophagia or the ingestion of hair [3]. The prevalence of trichobezoar is notably higher in young females, [4] with studies indicating that they can lead to significant gastrointestinal complications if left untreated, including obstruction, perforation [4, 5], and even life-threatening conditions such as Rapunzel syndrome, where a long tail of hair extends into the intestines [6].
The clinical presentation of trichobezoars can be diverse, often mimicking other gastrointestinal disorders. Common symptoms include abdominal pain, nausea, vomiting, and changes in bowel habits. In some cases, patients may present with more severe complications, such as bowel obstruction or jaundice due to biliary obstruction caused by large trichobezoars [5, 6, 7, 8]. A literature review reveals that managing trichobezoars typically involves a combination of surgical intervention and psychiatric support [9]. Diagnostic modalities such as abdominal ultrasound, computed tomography (CT), and endoscopy are crucial for accurately identifying trichobezoars, allowing for timely surgical intervention when necessary [10, 11]. In addressing the psychological aspects of trichotillomania and trichophagia, it is essential to recognize the interplay between psychiatric disorders and gastrointestinal manifestations. Therefore, the management of trichobezoars must extend beyond surgical intervention to include comprehensive psychiatric care [12-14].
In this case report, we present the clinical management of a 12-year-old child with untreated trichotillomania who developed a trichobezoar, describing the gastrointestinal signs and symptoms, diagnostic methods employed, surgical interventions, and the multifaceted treatment approach. In addition, we will review the published literature to provide an up-to-date review of trichobezoar management in children.

Case Presentation
A 12-year-old girl was brought to the Emergency Department of Bou-Ali Sina Hospital in Sari City, Mazandaran Province, Iran, with persistent nausea, vomiting, and abdominal pain that had intensified over the past 20 days. The vomiting was non-bilious and non-bloody, primarily occurring in the mornings. The abdominal pain worsened with solid foods, was not positional, did not radiate, and had no relation to bowel movements. The patient’s history included dietary changes, significant weight loss of about 5 kg over the past month, melena, anorexia, dysphagia, odynophagia, and fever. There was no personal or family history of peptic ulcers, dyspnea, diarrhea, or constipation. However, the family history revealed a grandfather with gastric cancer and a father with obsessive behaviors. Vital signs were stable (temperature: 37 °C, blood pressure: 90/60 mm Hg, heart rate: 100 bpm, respiratory rate: 22 breaths/min), and the patient appeared generally healthy despite her symptoms. Notably, she had been pulling and eating her hair for 4 years. Physical examination revealed normal bowel sounds and a tender, non-mobile mass measuring 13×22 cm from the upper to lower abdomen. Dullness on percussion in the upper abdomen suggested a large mass in the anatomical area of the stomach. Hepatomegaly or splenomegaly was absent. The patient exhibited patchy hair loss on her scalp with varying lengths distributed across normal-appearing skin. Laboratory tests showed normal white blood cell counts and hemoglobin levels. However, elevated urea (28 mg/dL), lactate dehydrogenase (370 u/L), alkaline phosphatase (483 u/L), and an elevated erythrocyte sedimentation rate (27 mm/h) indicated possible underlying gastrointestinal pathology. Imaging studies prior to surgery revealed no pathological lesions on chest x-ray. An abdominal ultrasound showed a mass with echogenic margins measuring 109 mm in the upper abdomen, possibly indicating a space-occupying lesion such as a bezoar. An erect abdominal x-ray demonstrated a heterogeneous shadow under the gastric air bubble. Non-contrast CT imaging revealed a distended stomach containing a sizeable heterogeneous mass lesion, almost filling the lumen with internal dense foci (Figure 1). Management involved laparotomy and removal of an abdominal trichobezoar under general anesthesia. A midline incision revealed an enlarged stomach with thickened walls. A longitudinal incision allowed for the removal of the trichobezoar measuring approximately 30 cm in length and weighing 1088 g—a mass entirely composed of hair (Figure 1). Pathology confirmed an intragastric mass (trichobezoar) measuring 2×13×5.4 cm. A psychiatric consultation indicated that the patient had been suffering from trichotillomania for 4 years without treatment. Considering these findings and her history, a diagnosis of trichobezoar was established. After discharge, she was referred for continued psychiatric treatment to address her underlying condition.

Discussion
This case report focuses on the clinical management of a 12-year-old child with untreated trichotillomania who developed a trichobezoar, highlighting the gastrointestinal symptoms, diagnostic techniques, and comprehensive treatment strategies employed. Additionally, we performed an extensive literature review using PubMed and Google Scholar without a time limit, utilizing MeSH terms such as “trichobezoar,” “bezoar,” and “pediatrics,” along with AND and OR operators. Our review included articles documenting cases of trichobezoar in children to enhance our understanding of its management (Table 1).




Bezoars are a concretion and accumulation of indigested or foreign materials in the gastrointestinal tract, and they are usually classified into phytobezoar, pharmacobezoar, trichobezoar, and lactobezoar [6, 10, 15, 16]. The accumulation and impaction of indigested hairs, food, and mucus in the stomach is called gastric trichobezoar and mostly affects females between 13 and 20 years of age [17-19]. In this disease, the swallowed hair remains in the stomach fold due to escaping peristaltic propulsion, and it assumes the shape of the stomach [6]. When the tail of the trichobezoar extends into the small intestine (duodenum, jejunum, and ileum) or to the colon, it is called Rapunzel syndrome [6, 20].
In this disease, patients usually have previous psychiatric diseases such as trichotillomania (hair pulling) and trichophagia (hair eating), and they might be with mental retardation and psychological problems [19, 21, 22]. Trichotillomania is a psychosomatic disorder in which the irresistible urge to pull out one’s hair causes significant hair loss and functional impairment. In this disorder, the patient feels calm and safe by pulling their hair from the head and other body parts. This condition is a habit disorder in children and has a better prognosis than trichotillomania in adults [23, 24]. Besides the patient’s hair, wigs, doll’s hair, and blankets are the other sources of trichobezoar hair [19].
The symptoms of trichobezoar range from none to severe, depending on the degree of obstruction [22, 25]. The complications include asymptomatic or chronic recurrent abdominal pain, nausea, vomiting, loss of appetite, and weight loss. Gastric perfusion is rare in this disease, but erosive gastritis, esophagitis, and ulcerations that lead to bleeding and/or perfusion are also trichobezoar complications [26, 27]. During the physical examination, a lump may be palpated in the epigastrium, and alopecia may be present [28]. 
Ultrasound, plain film, upper gastrointestinal tract endoscopy, and CT scan are diagnostic methods for trichobezoar. CT scan is a more accessible evaluation method, but the final diagnosis and gold standard is upper gastrointestinal endoscopy due to the direct view of trichobezoar [19, 28, 29].
In general, managing and treating trichobezoar includes removing the mass and dealing with the underlying psychiatric and physical causes to prevent the recurrence [6]. Trichobezoar can be treated by laparoscopy, laparotomy, or endoscopy. Endoscopic removal can only be effective for small trichobezoars, and repeated treatment attempts can lead to esophageal perforation, esophagitis, or pressure ulcers [22]. According to the study conducted by Gorter et al., the success rate of endoscopic treatment is 5%, laparoscopy is 75%, and laparotomy with a 100% success rate in trichobezoar treatment is the preferred treatment option for patients [9]. Follow-up and psychiatric treatment of patients is necessary to prevent and decrease recurrence [30].

Ethical Considerations
Compliance with ethical guidelines
Permission was obtained from the child’s parents to publish the current case report and any associated photographs. This article adheres to all relevant ethical principles. The patient and her parents have provided written informed consent for disseminating this manuscript and collecting images.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.


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