Giant gastric trichobezoar (Rapunzel syndrome) presenting as gastric outlet obstruction with imaging features suggestive of secondary superior mesenteric artery syndrome in a 27-year-old female: surgical management and multidisciplinary approach

Abstract Trichobezoars are rare intragastric masses composed of ingested hair, most commonly affecting young females with underlying psychiatric conditions. Rapunzel syndrome is a rare variant characterized by extension beyond the stomach into the small intestine. We report the case of a 27-year-old female with a 6-month history of abdominal pain, vomiting, weight loss, and intolerance to oral intake. Endoscopy revealed a large gastric trichobezoar occupying ~90% of the gastric lumen, causing functional pyloric obstruction. Contrast-enhanced computed tomography demonstrated marked gastric and proximal duodenal dilation with imaging features suggestive of secondary superior mesenteric artery (SMA) syndrome (Welsch T, Büchler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg 2007;24:149–56. https://doi.org/10.1159/000102097; Ganss A, Rampado S, Savarino E et al. Superior mesenteric artery syndrome: a prospective study in a single institution. J Gastrointest Surg 2019;23:997–1005. https://doi.org/10.1007/s11605-018-3984-6). Surgical exploration confirmed a giant trichobezoar extending from the pylorus to near the cardia with duodenal extension. Complete removal was achieved via laparotomy and anterior gastrotomy. The postoperative course was uneventful, and psychiatric evaluation confirmed trichotillomania and trichophagia. This case highlights the importance of multimodal diagnosis and suggests a possible pathophysiological relationship between severe gastric obstruction and secondary SMA syndrome.