REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
118
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
119
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
120
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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gástrico: reporte de un caso y revisión de la literatura. Rev Gastroenterol Peru. 2022 [cited 3 Apr 2026];
42(3):193-198. Available on: https://revistagastroperu.com/index.php/rgp/article/view/1343. DOI:
https://doi.org/10.47892/rgp.2022.423.1343.
2. Kwon H, Park J. Treatment of large gastric trichobezoar in children: two case reports and literature
review. Medicine (Baltimore). 2023 [cited 4 Apr 2026];102(16):e33589. Available on: https://pmc.ncbi.
nlm.nih.gov/articles/PMC10118359/. DOI: https://doi.org/10.1097/MD.0000000000033589.
3. Diallo I, Traore W, Zahraoui A, Moustapha E, Moatassim Billah N, Nassar I. Trichobezoar: a rare
cause of gastric obstruction. Glob Pediatr Health. 2023 [cited 3 Jan 2026];10:2333794X231165171.
Available on: https://journals.sagepub.com/doi/full/10.1177/2333794X231165171. DOI: https://doi.org/
10.1177/2333794X231165171.
4. Daoud R, Tlili A, Fendri S, Akrout A, Trigui A, Boujelbene S. Gastric trichobezoar: an uncommon
cause of epigastric pain: a case report. Clin Case Rep. 2022 [cited 6 Apr 2026];10(4):e05653. Available
on: https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.5653. DOI: https://doi.org/10.1002/ccr3.5653.
5. De Melio J, Debrouwere T, Herman M. Trichobezoar. J Belg Soc Radiol. 2021 [cited 8 Apr 2026];
105(1):31. Available on: https://pubmed.ncbi.nlm.nih.gov/34046551/. DOI: https://doi.org/10.5334/
jbsr.2478.
6. Kouskos E, Polychroni D, Rizou M, Andronikou A, Petrellis V. Gastric trichobezoar and Rapunzel
syndrome: case report of a very rare condition. Hippokratia. 2023 [cited 14 Apr 2026];27(1):25-27.
Available on: https://pmc.ncbi.nlm.nih.gov/articles/PMC10908309/.
7. Harrabi F, Ammar H, Ben Latifa M, Gupta R, Ben Ali A. Gastric trichobezoar causing gastrointestinal
bleeding: a case report. Cureus. 2022 [cited 16 Apr 2026];14(10):e30282. Available on: https://assets.
cureus.com/uploads/case_report/pdf/111791/20221113-13908-11kixhq.pdf. DOI: https://doi.org/
10.7759/cureus.30282.
8. Habib M, Amjad M, Abbas M, Chaudhary M. Gastric trichobezoars in pediatric population: a series
of six cases and literature review. Ann Med Surg (Lond). 2022 [cited 17 Apr 2026];84:104906.
Available on: https://www.sciencedirect.com/science/article/pii/S2049080122016661. DOI: https://
doi.org/10.1016/j.amsu.2022.104906.
9. Blanco Tapia S, Jauregui Paravicini L, Carvajal Tapia A. Tricobezoar gástrico y gastroduodenal en
pediatría: reporte de 2 casos e implicaciones quirúrgicas. Rev Fac Med (Mex). 2022 [cited 20 Apr
2026];65(4):24-9. Available on: https://www.scielo.org.mx/scielo.php?pid=S0026-174220220004
00024&script=sci_abstract&tlng=en. DOI: https://doi.org/10.22201/fm.24484865e.2022.65.4.03.
10. Khzam S, Obaidin A, Jlailati A, Barakat L, Alissa A, Khallouf S. Coexistence of bezoar and superior
mesenteric artery syndrome: a case report. Int J Surg Case Rep. 2025 [cited 24 Apr 2026];130:
111271. Available on: https://www.sciencedirect.com/science/article/pii/S2210261225004572. DOI:
https://doi.org/10.1016/j.ijscr.2025.111271.
11. Changas A, Louis M, Grabill N, Creel N. An unusual bezoar: elastic hair ties triggering small bowel
obstruction. Radiol Case Rep. 2025 [cited 25 Apr 2026];20(12):5909-13. Available on:
https://www.sciencedirect.com/science/article/pii/S1930043325007563. DOI: https://doi.org/
10.1016/j.radcr.2025.08.023.
12. Ali S, Rehman Usmani S, Zia A. Seed bezoars as a rare cause of fecal impaction in pediatric patients:
a report of two cases from Pakistan. J Pediatr Surg Case Rep. 2022 [cited 28 Apr 2026];86:102457.
Available on: https://www.sciencedirect.com/science/article/pii/S2213576622002846. DOI: https://
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population: a retrospective study. BMC Pediatr. 2024 [cited 7 May 2026];24(1):124. Available on:
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023-04489-x.
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19. Al-Mulla A, Altabeekh A, Al-Jafar A, Dashti S. Successful laparoscopic extraction of trichobezoar
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Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
121
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
REFERENCES
1. Huaco Aranguri A, Orduña Carpio R, Ortiz Castro C, Delgado Gonzales M, Haito Chávez Y. Tricobezoar
gástrico: reporte de un caso y revisión de la literatura. Rev Gastroenterol Peru. 2022 [cited 3 Apr 2026];
42(3):193-198. Available on: https://revistagastroperu.com/index.php/rgp/article/view/1343. DOI:
https://doi.org/10.47892/rgp.2022.423.1343.
2. Kwon H, Park J. Treatment of large gastric trichobezoar in children: two case reports and literature
review. Medicine (Baltimore). 2023 [cited 4 Apr 2026];102(16):e33589. Available on: https://pmc.ncbi.
nlm.nih.gov/articles/PMC10118359/. DOI: https://doi.org/10.1097/MD.0000000000033589.
3. Diallo I, Traore W, Zahraoui A, Moustapha E, Moatassim Billah N, Nassar I. Trichobezoar: a rare
cause of gastric obstruction. Glob Pediatr Health. 2023 [cited 3 Jan 2026];10:2333794X231165171.
Available on: https://journals.sagepub.com/doi/full/10.1177/2333794X231165171. DOI: https://doi.org/
10.1177/2333794X231165171.
4. Daoud R, Tlili A, Fendri S, Akrout A, Trigui A, Boujelbene S. Gastric trichobezoar: an uncommon
cause of epigastric pain: a case report. Clin Case Rep. 2022 [cited 6 Apr 2026];10(4):e05653. Available
on: https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.5653. DOI: https://doi.org/10.1002/ccr3.5653.
5. De Melio J, Debrouwere T, Herman M. Trichobezoar. J Belg Soc Radiol. 2021 [cited 8 Apr 2026];
105(1):31. Available on: https://pubmed.ncbi.nlm.nih.gov/34046551/. DOI: https://doi.org/10.5334/
jbsr.2478.
6. Kouskos E, Polychroni D, Rizou M, Andronikou A, Petrellis V. Gastric trichobezoar and Rapunzel
syndrome: case report of a very rare condition. Hippokratia. 2023 [cited 14 Apr 2026];27(1):25-27.
Available on: https://pmc.ncbi.nlm.nih.gov/articles/PMC10908309/.
7. Harrabi F, Ammar H, Ben Latifa M, Gupta R, Ben Ali A. Gastric trichobezoar causing gastrointestinal
bleeding: a case report. Cureus. 2022 [cited 16 Apr 2026];14(10):e30282. Available on: https://assets.
cureus.com/uploads/case_report/pdf/111791/20221113-13908-11kixhq.pdf. DOI: https://doi.org/
10.7759/cureus.30282.
8. Habib M, Amjad M, Abbas M, Chaudhary M. Gastric trichobezoars in pediatric population: a series
of six cases and literature review. Ann Med Surg (Lond). 2022 [cited 17 Apr 2026];84:104906.
Available on: https://www.sciencedirect.com/science/article/pii/S2049080122016661. DOI: https://
doi.org/10.1016/j.amsu.2022.104906.
9. Blanco Tapia S, Jauregui Paravicini L, Carvajal Tapia A. Tricobezoar gástrico y gastroduodenal en
pediatría: reporte de 2 casos e implicaciones quirúrgicas. Rev Fac Med (Mex). 2022 [cited 20 Apr
2026];65(4):24-9. Available on: https://www.scielo.org.mx/scielo.php?pid=S0026-174220220004
00024&script=sci_abstract&tlng=en. DOI: https://doi.org/10.22201/fm.24484865e.2022.65.4.03.
10. Khzam S, Obaidin A, Jlailati A, Barakat L, Alissa A, Khallouf S. Coexistence of bezoar and superior
mesenteric artery syndrome: a case report. Int J Surg Case Rep. 2025 [cited 24 Apr 2026];130:
111271. Available on: https://www.sciencedirect.com/science/article/pii/S2210261225004572. DOI:
https://doi.org/10.1016/j.ijscr.2025.111271.
11. Changas A, Louis M, Grabill N, Creel N. An unusual bezoar: elastic hair ties triggering small bowel
obstruction. Radiol Case Rep. 2025 [cited 25 Apr 2026];20(12):5909-13. Available on:
https://www.sciencedirect.com/science/article/pii/S1930043325007563. DOI: https://doi.org/
10.1016/j.radcr.2025.08.023.
12. Ali S, Rehman Usmani S, Zia A. Seed bezoars as a rare cause of fecal impaction in pediatric patients:
a report of two cases from Pakistan. J Pediatr Surg Case Rep. 2022 [cited 28 Apr 2026];86:102457.
Available on: https://www.sciencedirect.com/science/article/pii/S2213576622002846. DOI: https://
doi.org/10.1016/j.epsc.2022.102457.
13. Khoshnazar S, Eslami O. Colon obstruction due to sunflower seed bezoar: a case report. Int J Surg
Case Rep. 2025 [cited 15 May 2026];128:110841. Available on: https://www.sciencedirect.com/
science/article/pii/S2210261225000276. DOI: https://doi.org/10.1016/j.ijscr.2025.110841.
14. Deo K, Yogi P, Rokaya D, KC A. Multiple gastrointestinal bezoars leading to perforation peritonitis:
a case report. Int J Surg Case Rep. 2025 [cited 11 May 2026];134:111700. Available on:
https://www.sciencedirect.com/science/article/pii/S2210261225008867. DOI: https://doi.org/10.1016/
j.ijscr.2025.111700.
15. Wang L, Chen Y, Chen S, Gao Z, Qian Y, Chen Q. Gastrointestinal trichobezoars in the pediatric
population: a retrospective study. BMC Pediatr. 2024 [cited 7 May 2026];24(1):124. Available on:
https://link.springer.com/article/10.1186/s12887-023-04489-x. DOI: https://doi.org/10.1186/s12887-
023-04489-x.
16. Kaba M, Karadağ Ç, Sever N, Ser İ, Demir M, Yıldız A, et al. A rare cause of intestinal obstruction
in children trichobezoar: how to diagnose? Ulus Travma Acil Cerrahi Derg. 2023 [cited 5 May
2026];29(11):1288-1295. Available on: https://pdf.journalagent.com/travma/pdfs/UTD_29_11_1288_
1295.pdf. DOI: https://doi.org/10.14744/tjtes.2023.08434.
17. Amezquita S, Escobar S, Soler C, Celis L. Gastric trichobezoar: late manifestation of a behavioral
disorder in childhood. Acta Pediatr Mex. 2025 [cited 2 May 2026];46(1):97-102. Available on:
https://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=119821. DOI: https://doi.org/
10.18233/apm.v46i1.2821.
18. Almoallim R, Safa N, Patel A, Flageole H, Barakzai M. Pediatric case of trichobezoar leading to
gastric perforation. Radiol Case Rep. 2026 [cited 22 May 2026];21(3):1121-6. Available on:
https://www.sciencedirect.com/science/article/pii/S1930043325010763. DOI: https://doi.org/
10.1016/j.radcr.2025.11.060.
19. Al-Mulla A, Altabeekh A, Al-Jafar A, Dashti S. Successful laparoscopic extraction of trichobezoar
due to Rapunzel syndrome: first reported case in Kuwait. J Surg Case Rep. 2021 [cited 20 May 2026];
2021(12):rjab532. Available on: https://academic.oup.com/jscr/article/2021/12/rjab532/6455022.
DOI: https://doi.org/10.1093/jscr/rjab532.
20. Parvizi Mashhadi M, Shipman K. Minimally invasive surgery for intragastric trichobezoar in pediatrics:
a case report. Int J Surg Case Rep. 2025 [cited 25 May 2026];133:111649. Available on:
https://www.sciencedirect.com/science/article/pii/S2210261225008351. DOI: https://doi.org/10.1016/
j.ijscr.2025.111649.
21. González García I, García Fernández A, Pérez Martínez M. Síndrome de Rapunzel más que una
leyenda infantil: caso clínico pediátrico. Arch Med Camaguey [Internet]. 2023 [cited 17 May 2026].
Available on: https://revistaamc.sld.cu/index.php/amc/article/view/7648/4167.
22. Ventura D, Herbella F, Schettini S, Delmonte C. Trichobezoar causing gastric perforation: a case
report. World J Gastroenterol. 2005[cited 7 May 2026];11(20):3268-70. Available on: https://pmc.ncbi.
nlm.nih.gov/articles/PMC4691274/.
Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
122
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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10.1016/j.radcr.2025.08.023.
12. Ali S, Rehman Usmani S, Zia A. Seed bezoars as a rare cause of fecal impaction in pediatric patients:
a report of two cases from Pakistan. J Pediatr Surg Case Rep. 2022 [cited 28 Apr 2026];86:102457.
Available on: https://www.sciencedirect.com/science/article/pii/S2213576622002846. DOI: https://
doi.org/10.1016/j.epsc.2022.102457.
13. Khoshnazar S, Eslami O. Colon obstruction due to sunflower seed bezoar: a case report. Int J Surg
Case Rep. 2025 [cited 15 May 2026];128:110841. Available on: https://www.sciencedirect.com/
science/article/pii/S2210261225000276. DOI: https://doi.org/10.1016/j.ijscr.2025.110841.
14. Deo K, Yogi P, Rokaya D, KC A. Multiple gastrointestinal bezoars leading to perforation peritonitis:
a case report. Int J Surg Case Rep. 2025 [cited 11 May 2026];134:111700. Available on:
https://www.sciencedirect.com/science/article/pii/S2210261225008867. DOI: https://doi.org/10.1016/
j.ijscr.2025.111700.
15. Wang L, Chen Y, Chen S, Gao Z, Qian Y, Chen Q. Gastrointestinal trichobezoars in the pediatric
population: a retrospective study. BMC Pediatr. 2024 [cited 7 May 2026];24(1):124. Available on:
https://link.springer.com/article/10.1186/s12887-023-04489-x. DOI: https://doi.org/10.1186/s12887-
023-04489-x.
16. Kaba M, Karadağ Ç, Sever N, Ser İ, Demir M, Yıldız A, et al. A rare cause of intestinal obstruction
in children trichobezoar: how to diagnose? Ulus Travma Acil Cerrahi Derg. 2023 [cited 5 May
2026];29(11):1288-1295. Available on: https://pdf.journalagent.com/travma/pdfs/UTD_29_11_1288_
1295.pdf. DOI: https://doi.org/10.14744/tjtes.2023.08434.
17. Amezquita S, Escobar S, Soler C, Celis L. Gastric trichobezoar: late manifestation of a behavioral
disorder in childhood. Acta Pediatr Mex. 2025 [cited 2 May 2026];46(1):97-102. Available on:
https://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=119821. DOI: https://doi.org/
10.18233/apm.v46i1.2821.
18. Almoallim R, Safa N, Patel A, Flageole H, Barakzai M. Pediatric case of trichobezoar leading to
gastric perforation. Radiol Case Rep. 2026 [cited 22 May 2026];21(3):1121-6. Available on:
https://www.sciencedirect.com/science/article/pii/S1930043325010763. DOI: https://doi.org/
10.1016/j.radcr.2025.11.060.
19. Al-Mulla A, Altabeekh A, Al-Jafar A, Dashti S. Successful laparoscopic extraction of trichobezoar
due to Rapunzel syndrome: first reported case in Kuwait. J Surg Case Rep. 2021 [cited 20 May 2026];
2021(12):rjab532. Available on: https://academic.oup.com/jscr/article/2021/12/rjab532/6455022.
DOI: https://doi.org/10.1093/jscr/rjab532.
20. Parvizi Mashhadi M, Shipman K. Minimally invasive surgery for intragastric trichobezoar in pediatrics:
a case report. Int J Surg Case Rep. 2025 [cited 25 May 2026];133:111649. Available on:
https://www.sciencedirect.com/science/article/pii/S2210261225008351. DOI: https://doi.org/10.1016/
j.ijscr.2025.111649.
21. González García I, García Fernández A, Pérez Martínez M. Síndrome de Rapunzel más que una
leyenda infantil: caso clínico pediátrico. Arch Med Camaguey [Internet]. 2023 [cited 17 May 2026].
Available on: https://revistaamc.sld.cu/index.php/amc/article/view/7648/4167.
22. Ventura D, Herbella F, Schettini S, Delmonte C. Trichobezoar causing gastric perforation: a case
report. World J Gastroenterol. 2005[cited 7 May 2026];11(20):3268-70. Available on: https://pmc.ncbi.
nlm.nih.gov/articles/PMC4691274/.
Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
REE 20(3) Riobamba sep. - dic. 2026
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BY NC ND
123
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
124
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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8. Habib M, Amjad M, Abbas M, Chaudhary M. Gastric trichobezoars in pediatric population: a series
of six cases and literature review. Ann Med Surg (Lond). 2022 [cited 17 Apr 2026];84:104906.
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19. Al-Mulla A, Altabeekh A, Al-Jafar A, Dashti S. Successful laparoscopic extraction of trichobezoar
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Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
REFERENCES
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nlm.nih.gov/articles/PMC10118359/. DOI: https://doi.org/10.1097/MD.0000000000033589.
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Available on: https://journals.sagepub.com/doi/full/10.1177/2333794X231165171. DOI: https://doi.org/
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cause of epigastric pain: a case report. Clin Case Rep. 2022 [cited 6 Apr 2026];10(4):e05653. Available
on: https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.5653. DOI: https://doi.org/10.1002/ccr3.5653.
5. De Melio J, Debrouwere T, Herman M. Trichobezoar. J Belg Soc Radiol. 2021 [cited 8 Apr 2026];
105(1):31. Available on: https://pubmed.ncbi.nlm.nih.gov/34046551/. DOI: https://doi.org/10.5334/
jbsr.2478.
6. Kouskos E, Polychroni D, Rizou M, Andronikou A, Petrellis V. Gastric trichobezoar and Rapunzel
syndrome: case report of a very rare condition. Hippokratia. 2023 [cited 14 Apr 2026];27(1):25-27.
Available on: https://pmc.ncbi.nlm.nih.gov/articles/PMC10908309/.
7. Harrabi F, Ammar H, Ben Latifa M, Gupta R, Ben Ali A. Gastric trichobezoar causing gastrointestinal
bleeding: a case report. Cureus. 2022 [cited 16 Apr 2026];14(10):e30282. Available on: https://assets.
cureus.com/uploads/case_report/pdf/111791/20221113-13908-11kixhq.pdf. DOI: https://doi.org/
10.7759/cureus.30282.
8. Habib M, Amjad M, Abbas M, Chaudhary M. Gastric trichobezoars in pediatric population: a series
of six cases and literature review. Ann Med Surg (Lond). 2022 [cited 17 Apr 2026];84:104906.
Available on: https://www.sciencedirect.com/science/article/pii/S2049080122016661. DOI: https://
doi.org/10.1016/j.amsu.2022.104906.
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pediatría: reporte de 2 casos e implicaciones quirúrgicas. Rev Fac Med (Mex). 2022 [cited 20 Apr
2026];65(4):24-9. Available on: https://www.scielo.org.mx/scielo.php?pid=S0026-174220220004
00024&script=sci_abstract&tlng=en. DOI: https://doi.org/10.22201/fm.24484865e.2022.65.4.03.
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mesenteric artery syndrome: a case report. Int J Surg Case Rep. 2025 [cited 24 Apr 2026];130:
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10.1016/j.radcr.2025.08.023.
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Available on: https://www.sciencedirect.com/science/article/pii/S2213576622002846. DOI: https://
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Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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42(3):193-198. Available on: https://revistagastroperu.com/index.php/rgp/article/view/1343. DOI:
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nlm.nih.gov/articles/PMC10118359/. DOI: https://doi.org/10.1097/MD.0000000000033589.
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Available on: https://journals.sagepub.com/doi/full/10.1177/2333794X231165171. DOI: https://doi.org/
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on: https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.5653. DOI: https://doi.org/10.1002/ccr3.5653.
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Available on: https://pmc.ncbi.nlm.nih.gov/articles/PMC10908309/.
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bleeding: a case report. Cureus. 2022 [cited 16 Apr 2026];14(10):e30282. Available on: https://assets.
cureus.com/uploads/case_report/pdf/111791/20221113-13908-11kixhq.pdf. DOI: https://doi.org/
10.7759/cureus.30282.
8. Habib M, Amjad M, Abbas M, Chaudhary M. Gastric trichobezoars in pediatric population: a series
of six cases and literature review. Ann Med Surg (Lond). 2022 [cited 17 Apr 2026];84:104906.
Available on: https://www.sciencedirect.com/science/article/pii/S2049080122016661. DOI: https://
doi.org/10.1016/j.amsu.2022.104906.
9. Blanco Tapia S, Jauregui Paravicini L, Carvajal Tapia A. Tricobezoar gástrico y gastroduodenal en
pediatría: reporte de 2 casos e implicaciones quirúrgicas. Rev Fac Med (Mex). 2022 [cited 20 Apr
2026];65(4):24-9. Available on: https://www.scielo.org.mx/scielo.php?pid=S0026-174220220004
00024&script=sci_abstract&tlng=en. DOI: https://doi.org/10.22201/fm.24484865e.2022.65.4.03.
10. Khzam S, Obaidin A, Jlailati A, Barakat L, Alissa A, Khallouf S. Coexistence of bezoar and superior
mesenteric artery syndrome: a case report. Int J Surg Case Rep. 2025 [cited 24 Apr 2026];130:
111271. Available on: https://www.sciencedirect.com/science/article/pii/S2210261225004572. DOI:
https://doi.org/10.1016/j.ijscr.2025.111271.
REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
126
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
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obstruction. Radiol Case Rep. 2025 [cited 25 Apr 2026];20(12):5909-13. Available on:
https://www.sciencedirect.com/science/article/pii/S1930043325007563. DOI: https://doi.org/
10.1016/j.radcr.2025.08.023.
12. Ali S, Rehman Usmani S, Zia A. Seed bezoars as a rare cause of fecal impaction in pediatric patients:
a report of two cases from Pakistan. J Pediatr Surg Case Rep. 2022 [cited 28 Apr 2026];86:102457.
Available on: https://www.sciencedirect.com/science/article/pii/S2213576622002846. DOI: https://
doi.org/10.1016/j.epsc.2022.102457.
13. Khoshnazar S, Eslami O. Colon obstruction due to sunflower seed bezoar: a case report. Int J Surg
Case Rep. 2025 [cited 15 May 2026];128:110841. Available on: https://www.sciencedirect.com/
science/article/pii/S2210261225000276. DOI: https://doi.org/10.1016/j.ijscr.2025.110841.
14. Deo K, Yogi P, Rokaya D, KC A. Multiple gastrointestinal bezoars leading to perforation peritonitis:
a case report. Int J Surg Case Rep. 2025 [cited 11 May 2026];134:111700. Available on:
https://www.sciencedirect.com/science/article/pii/S2210261225008867. DOI: https://doi.org/10.1016/
j.ijscr.2025.111700.
15. Wang L, Chen Y, Chen S, Gao Z, Qian Y, Chen Q. Gastrointestinal trichobezoars in the pediatric
population: a retrospective study. BMC Pediatr. 2024 [cited 7 May 2026];24(1):124. Available on:
https://link.springer.com/article/10.1186/s12887-023-04489-x. DOI: https://doi.org/10.1186/s12887-
023-04489-x.
16. Kaba M, Karadağ Ç, Sever N, Ser İ, Demir M, Yıldız A, et al. A rare cause of intestinal obstruction
in children trichobezoar: how to diagnose? Ulus Travma Acil Cerrahi Derg. 2023 [cited 5 May
2026];29(11):1288-1295. Available on: https://pdf.journalagent.com/travma/pdfs/UTD_29_11_1288_
1295.pdf. DOI: https://doi.org/10.14744/tjtes.2023.08434.
17. Amezquita S, Escobar S, Soler C, Celis L. Gastric trichobezoar: late manifestation of a behavioral
disorder in childhood. Acta Pediatr Mex. 2025 [cited 2 May 2026];46(1):97-102. Available on:
https://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=119821. DOI: https://doi.org/
10.18233/apm.v46i1.2821.
18. Almoallim R, Safa N, Patel A, Flageole H, Barakzai M. Pediatric case of trichobezoar leading to
gastric perforation. Radiol Case Rep. 2026 [cited 22 May 2026];21(3):1121-6. Available on:
https://www.sciencedirect.com/science/article/pii/S1930043325010763. DOI: https://doi.org/
10.1016/j.radcr.2025.11.060.
19. Al-Mulla A, Altabeekh A, Al-Jafar A, Dashti S. Successful laparoscopic extraction of trichobezoar
due to Rapunzel syndrome: first reported case in Kuwait. J Surg Case Rep. 2021 [cited 20 May 2026];
2021(12):rjab532. Available on: https://academic.oup.com/jscr/article/2021/12/rjab532/6455022.
DOI: https://doi.org/10.1093/jscr/rjab532.
20. Parvizi Mashhadi M, Shipman K. Minimally invasive surgery for intragastric trichobezoar in pediatrics:
a case report. Int J Surg Case Rep. 2025 [cited 25 May 2026];133:111649. Available on:
https://www.sciencedirect.com/science/article/pii/S2210261225008351. DOI: https://doi.org/10.1016/
j.ijscr.2025.111649.
21. González García I, García Fernández A, Pérez Martínez M. Síndrome de Rapunzel más que una
leyenda infantil: caso clínico pediátrico. Arch Med Camaguey [Internet]. 2023 [cited 17 May 2026].
Available on: https://revistaamc.sld.cu/index.php/amc/article/view/7648/4167.
22. Ventura D, Herbella F, Schettini S, Delmonte C. Trichobezoar causing gastric perforation: a case
report. World J Gastroenterol. 2005[cited 7 May 2026];11(20):3268-70. Available on: https://pmc.ncbi.
nlm.nih.gov/articles/PMC4691274/.
Giant gastric trichobezoar with perforation at the angular incisura and omental sealing in a 7-year-old
patient: Case report
Tricobezoar gástrico gigante con perforación en incisura angularis y sellamiento epiploico en paciente
de 7 años: Reporte de caso
https://doi.org/10.37135/ee.04.27.08
Authors:
Brayan José Vargas-Lucio1 *- https://orcid.org/0009-0009-0724-7480
Jhoanss Sebastian Gaibor-Gaibor2 - https://orcid.org/0009-0008-8325-8395
Gabriel Israel García-Gaibor3 - https://orcid.org/0009-0007-6666-6808
Alex Vinicio Almache-Palacios1 - https://orcid.org/0009-0003-9983-7336
Katerin Mishel García-Gaibor4 - https://orcid.org/0009-0009-3506-9052
Affiliation:
1Higher Polytechnic School of Chimborazo, Riobamba, Ecuador.
2University of the Americas, Quito, Ecuador.
3Puyo General Hospital , Puyo, Ecuador.
4University of Guayaquil, Guayaquil, Ecuador.
Corresponding author: Brayan José Vargas Lucio. Escuela Superior Politécnica de Chimborazo, Panamericana
Sur km 1 ½ Av. Canónigo Ramos and Av. 11 de Noviembre. Zip code: EC060155. Email: vargas.brayanj@gmail.-
com. Telephone: +593959065526
Received: March, 12 2026 Accepted: Juny, 28 2026
ABSTRACT
A trichobezoar is a condition characterized by the formation of a hair mass in the stomach, associated with
trichotillomania and trichophagia. The case of a 7-year-old patient with abdominal pain is presented. An
abdominal ultrasound revealed an irregular hyperechoic mass, which was confirmed by non-contrast and
contrast-enhanced computed tomography. Surgical intervention revealed a 20 cm trichobezoar adhered to the
gastric mucosa, with a perforation at the incisura angularis. The diagnosis of trichobezoar is rare, but if not
recognized promptly, it can lead to serious complications. The mass size is a significant obstacle to surgical
intervention.
Keywords: Trichotillomania, Stomach, Surgical Procedures
RESUMEN
El tricobezoar es una patología caracterizada por la formación de una masa de cabello a nivel gástrico,
relacionada con la tricotilomanía y tricofagia. Se presenta el caso de una paciente de 7 años con dolor abdominal,
quien a la realización de ecografía abdominal muestra masa hiperecogénica irregular, confirmada por
tomografía simple y contrastada. Se realizó una intervención quirúrgica, resultando un tricobezoar de 20
cm adherido a mucosa gástrica con perforación en incisura angularis. El diagnóstico de tricobezoar es raro,
pero si no se reconoce rápidamente puede llevar a complicaciones graves. El tamaño constituye un obstáculo
de importancia cuando se considera la resolución quirúrgica.
Palabras clave: tricotilomanía, estómago, procedimientos quirúrgicos operativos.
INTRODUCTION
Trichobezoar is a particularly rare gastrointestinal pathology consisting of an intraluminal mass of hair that
is indigestible or difficult to digest and accumulates in the digestive tract. Trichobezoar is closely related to
trichotillomania, the compulsion to pull out hair, and trichophagia, the compulsion to ingest hair.
(1–3)
This
disorder is very rare, occurring in less than 1% of the general population. Ninety percent of cases are reported
in young women with long hair between the ages of 13 and 20. These cases have been associated with
trichotillomania, trichophagia, and mental disorders such as obsessive thinking, mood swings, and anxiety.
(4–6 )
They can occur in any segment of the gastrointestinal tract, but most commonly form in the stomach. A com-
plication known as Rapunzel syndrome occurs when the mass extends beyond the gastroduodenal junc-
tion.
(6,8)
Early onset of symptoms is rare, and the patient usually remains asymptomatic or presents only with
mild abdominal pain. Hair ingestion continues until the size of the mass causes severe pain along with
obstructive symptoms.
(1,7)
Treatment may be surgical, consisting of removal of the mass, either by endoscopy,
laparoscopy, or laparotomy. If left untreated, the condition can progress to gastric erosion and subsequent
ulceration, hemorrhage, or perforation.
(7–9)
The patient's parents provided informed consent for publication of this case and clinical images, and we
ensured the confidentiality of their personal information. In this context, we present the case of a 7-year-old
female patient from and residing in the eastern region of Ecuador, with abdominal pain.
CASE PRESENTATION
A 7-year-old female patient from the tropical region of Ecuador, with no known medical, surgical, or family
history, and no known allergies, presented to the emergency department of a secondary-level hospital with
an abdominal mass that had been present for 3 months. She also reported abdominal pain that began 2 days
prior, located in the epigastrium, of moderate intensity, colicky in nature, without radiation, progressive, and
without any relieving or exacerbating factors. Her mother reported behavior consistent with trichotillomania,
trichophagia, and pica, with a presumed duration of 4 years, characterized by hair pulling and ingestion,
along with pieces of mattress. The mother stated that there were no conflicts within the family and acknowledged
limited supervision of the child, with no history of prior psychiatric or psychological evaluation. On physical
examination, the patient was oriented to person, place, and time. The abdomen was tender to palpation, and a
firm, regularly shaped mass, approximately 8 cm in diameter, was found in the epigastric region. No peritoneal
irritation was noted, and the patient was admitted. A complete blood count revealed leukocytosis and anemia
(8.2 g/dL). Abdominal ultrasound showed an irregular, hyperechoic, solid mass measuring 7.21 x 4.81 x 6.87
cm within the stomach. Non-contrast and contrast-enhanced computed tomography (CT) of the abdomen
revealed a space-occupying lesion in the stomach, suggestive of a bezoar. On the fifth day of hospitalization,
leukocytosis with a left shift was observed compared to the initial blood work, along with an elevated
C-reactive protein (CRP) level. Hemoglobin decreased markedly to 7.7 g/dL on the fourth day of hospitalization
and to 6.6 g/dL two days later, prompting a transfusion of one unit of packed red blood cells without buffy
coat. On the sixth day, an exploratory laparotomy was performed, revealing an enlarged stomach with a mass
at the level of the angular incisura on the anterior wall. The stomach was covered by omentum and
fibrinopurulent mucus, and a trichobezoar approximately 20 cm in diameter was firmly adhered to the
gastric mucosa (Figures 1 and 2). A gastric perforation at the level of the angular incisura was covered and
sealed by a firmly adhered greater omentum, fused to the wall like a Graham patch, with fibrous tissue edges.
There were no signs of bleeding or perforation, scant fluid in the abdomen, and no evidence of gastric
contents spilling into the abdominal cavity. The postoperative course was uneventful. Psychology evaluated
the patient and recommended follow-up, individual and family support, psychoeducation, psychological
interviews, and active, empathetic listening. During hospitalization, the patient received antibiotic therapy
with a third-generation cephalosporin and a nitroimidazole for six days, along with antiemetics, analgesics,
and proton pump inhibitors. On the tenth day of hospitalization and the fourth postoperative day, the patient
showed favorable clinical progress, with regular bowel movements and adequate urine output. The team
ordered discharge, and the patient was instructed to complete the therapeutic regimen at home, with
follow-up appointments in pediatrics, psychology, and general surgery.
Figure 1. Extraction of trichobezoar by gastrotomy
Source: Patient's medical record.
Figure 2. Extracted gastric trichobezoar
Source: Patient's medical record.
DISCUSSION
Bezoars present a clinical challenge, acting as a barrier that hinders the normal passage of food through the
gastrointestinal tract when indigestible material is consumed. Based on their composition and origin, they are
classified as phytobezoars (plant material), trichobezoars (hair), pharmacobezoars (medications), and
lactobezoars (milk). Phytobezoars are the most common; however, it is important to differentiate between
age groups and risk factors. In pediatrics, particularly in girls and adolescents with a history of trichophagia,
trichobezoars are predominant. This highlights the need for a comprehensive, individualized approach across
different risk groups.
(10–12)
It is considered a rare pathology, with an incidence of less than 0.5–1% detected during upper gastrointestinal
endoscopy (UGE). Depending on its size, it can go undetected for a prolonged period, as in the case
presented. Ecuador has few reported cases, which makes it difficult to establish epidemiological data in
this country.
(11,13)
Symptom onset depends on the size and location of the trichobezoar. In the vast majority of cases, it
manifests as a multisymptomatic process, the main symptom being abdominal pain associated with nausea,
vomiting, or abdominal distension. Even so, smaller trichobezoars may be asymptomatic or present with
nonspecific symptoms that can be mistaken for other digestive disorders and delay diagnosis. In exceptional
situations, complications such as intestinal obstruction, gastrointestinal bleeding, or gastric ulcers may
occur.
(12–14)
This pathology is more frequently associated with females with a history of trichophagia; for its diagnosis,
the patient's clinical presentation combined with imaging studies is fundamental, with UGE being the gold
standard, especially in pediatric patients.
(15)
This imaging study allows direct visualization of the gastric mucosa, facilitating timely biopsy and early
detection of associated complications, such as perforations or ulcers; thus, it has a high predictive value, with
a 95% success rate for diagnosis. According to Wang et al., UGE has high sensitivity for confirming gastric
trichobezoars, with a statistically significant correlation in 15 out of 16 patients examined.
(9,15)
Ultrasound is a non-invasive method of increasing clinical relevance, especially in pediatric patients, as it
avoids radiation. In most cases, this study indicates well-defined masses with hyperechoic characteristics
that produce acoustic shadowing in 33.3% of cases.
(16)
Computed tomography (CT) reveals areas of mixed density, allowing identification of extension to adjacent
anatomical structures, such as the small intestine, facilitating diagnosis of Rapunzel syndrome in approxima-
tely 35% of cases and helping detect intestinal obstruction.
(15)
Plain abdominal radiography shows gastric opacity in approximately 28.6% of cases, but it is nonspecific
and of low diagnostic utility.
(9)
Therapeutic management of giant gastric trichobezoars in pediatric patients, as in the present case, involves
complete removal, which reduces the risk of serious complications such as intestinal obstruction or perforation.
Surgical technique is prioritized because current endoscopic approaches have inherent limitations.
(15,17)
Exploratory laparotomy with anterior gastrotomy is the gold standard for treatment, especially for giant
trichobezoars, allowing for complete removal of the bezoar.
(9,18)
However, minimally invasive laparoscopy
has proven to be a safe and effective alternative; it consists of removing the bezoar using an endoscopic bag
( endo-bag), which allows for a reduction of the incision by approximately 3 cm compared to conventional
techniques, intending to inhibit intestinal extension, thus favoring postoperative recovery. This technique
represents an advance over conventional laparotomy, balancing efficacy with faster recovery in centers with
laparoscopic experience.
(19,20)
In pediatric patients, complications from giant trichobezoars are common because their large volume can
occupy up to 80% of the gastric cavity, generating mechanical pressure. This occupancy can increase the risk
of complications such as intestinal obstruction, ulcers, and perforations, which are frequent manifestations
with a high mortality rate.
(21)
Rapunzel syndrome has an incidence of 35 % in giant trichobezoars and is characterized by pyloric extension
into the duodenum, causing intestinal obstruction. In this patient, the clinical complexity was exacerbated
by involvement of critical anatomical structures, such as the angular incisura, with development of a
fibrinopurulent phlegmon covered by omentum, substantially increasing the risk of secondary peritonitis.
(18,22)
This case is relevant due to its atypical age of onset, as it is more common in adolescents aged 13 to 20. The
clinical history is also important because trichotillomania, trichophagia, and pica have an underlying
psychobiological component. The gradual onset, with nonspecific associated pain, complicates the diagnostic
process, making it crucial to consider psychiatric disorders as a factor in chronic digestive symptoms. This
case highlights the importance of a multidisciplinary approach that integrates psychological, clinical, and
social factors to support timely diagnosis and management, thereby preventing complications.
CONCLUSIONS
In conclusion, trichobezoars remain an uncommon condition, secondary to behavioral and eating disorders
such as trichotillomania, trichophagia, and pica. Timely diagnosis is essential to prevent progression to
serious complications. Prompt surgical intervention is the gold standard in the management of giant trichobezoars,
along with psychiatric evaluation and the inclusion of cognitive-behavioral therapies combined with selective
serotonin reuptake inhibitors (SSRIs) when necessary, as part of a multidisciplinary approach. Long-term
follow-up is also crucial to manage risky behaviors, prevent recurrence, and avoid future complications.
Funding: The authors funded this work.
Acknowledgments: The authors thank Puyo General Hospital for the facilities provided for the patient's care
and the preparation of this case report.
Conflicts of interest: There are no conflicts of interest on the part of the authors.
Contribution statement:
Brayan José Vargas Lucio: Conception and design of the study, leadership in the collection of clinical data,
main writing and initial structuring of the manuscript, general supervision of the work, critical review of the
scientific content and final approval of the version to be published.
Jhoanss Sebastian Gaibor Gaibor: Substantial participation in the conception of the work, collection and
interpretation of clinical and imaging data, direct collaboration in the writing of the manuscript and critical
review of the scientific content.
Gabriel Israel García Gaibor: Analysis and interpretation of clinical information; bibliographic review and
contribution to the writing of sections of the manuscript.
Alex Vinicio Almache Palacios: Interpretation of clinical findings and critical review of the manuscript with
relevant intellectual contributions.
Katerin Mishel García Gaibor: Analysis and interpretation of clinical information, literature review and
contribution to the writing of sections of the manuscript.
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https://www.sciencedirect.com/science/article/pii/S2210261225008867. DOI: https://doi.org/10.1016/
j.ijscr.2025.111700.
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population: a retrospective study. BMC Pediatr. 2024 [cited 7 May 2026];24(1):124. Available on:
https://link.springer.com/article/10.1186/s12887-023-04489-x. DOI: https://doi.org/10.1186/s12887-
023-04489-x.
16. Kaba M, Karadağ Ç, Sever N, Ser İ, Demir M, Yıldız A, et al. A rare cause of intestinal obstruction
in children trichobezoar: how to diagnose? Ulus Travma Acil Cerrahi Derg. 2023 [cited 5 May
2026];29(11):1288-1295. Available on: https://pdf.journalagent.com/travma/pdfs/UTD_29_11_1288_
1295.pdf. DOI: https://doi.org/10.14744/tjtes.2023.08434.
17. Amezquita S, Escobar S, Soler C, Celis L. Gastric trichobezoar: late manifestation of a behavioral
disorder in childhood. Acta Pediatr Mex. 2025 [cited 2 May 2026];46(1):97-102. Available on:
https://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=119821. DOI: https://doi.org/
10.18233/apm.v46i1.2821.
18. Almoallim R, Safa N, Patel A, Flageole H, Barakzai M. Pediatric case of trichobezoar leading to
gastric perforation. Radiol Case Rep. 2026 [cited 22 May 2026];21(3):1121-6. Available on:
https://www.sciencedirect.com/science/article/pii/S1930043325010763. DOI: https://doi.org/
10.1016/j.radcr.2025.11.060.
REE 20(3) Riobamba sep. - dic. 2026
cc
BY NC ND
127
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
19. Al-Mulla A, Altabeekh A, Al-Jafar A, Dashti S. Successful laparoscopic extraction of trichobezoar
due to Rapunzel syndrome: first reported case in Kuwait. J Surg Case Rep. 2021 [cited 20 May 2026];
2021(12):rjab532. Available on: https://academic.oup.com/jscr/article/2021/12/rjab532/6455022.
DOI: https://doi.org/10.1093/jscr/rjab532.
20. Parvizi Mashhadi M, Shipman K. Minimally invasive surgery for intragastric trichobezoar in pediatrics:
a case report. Int J Surg Case Rep. 2025 [cited 25 May 2026];133:111649. Available on:
https://www.sciencedirect.com/science/article/pii/S2210261225008351. DOI: https://doi.org/10.1016/
j.ijscr.2025.111649.
21. González García I, García Fernández A, Pérez Martínez M. Síndrome de Rapunzel más que una
leyenda infantil: caso clínico pediátrico. Arch Med Camaguey [Internet]. 2023 [cited 17 May 2026].
Available on: https://revistaamc.sld.cu/index.php/amc/article/view/7648/4167.
22. Ventura D, Herbella F, Schettini S, Delmonte C. Trichobezoar causing gastric perforation: a case
report. World J Gastroenterol. 2005[cited 7 May 2026];11(20):3268-70. Available on: https://pmc.ncbi.
nlm.nih.gov/articles/PMC4691274/.
