A Teenager's Unexplained Abdominal Pain: The Hidden Hairball Diagnosis

Table of Contents

• Background: Why This Case Matters
• Case Presentation: The Patient's Story
• Examination and Test Results
• Differential Diagnosis: What Could It Be?
• Final Diagnosis: Trichobezoar (Hairball)
• Clinical Management: Treatment Approach
• Psychiatric Aspects: Understanding the Root Cause
• What This Means for Patients
• Source Information

Background: Why This Case Matters

This case illustrates how seemingly unexplained abdominal symptoms can sometimes have surprising causes that require careful detective work by medical teams. For patients experiencing persistent gastrointestinal issues, this case demonstrates the importance of considering both physical and psychological factors that might contribute to their condition.

The patient's story shows how conditions that begin as behavioral patterns can evolve into serious medical problems requiring surgical intervention. This intersection of mental health and physical health is crucial for both patients and doctors to understand.

Case Presentation: The Patient's Story

A 16-year-old girl developed intermittent abdominal pain that progressively worsened over four weeks. Initially occurring every few days, the pain episodes increased to twice daily, each lasting approximately 2 minutes. Two weeks into her symptoms, she developed nausea and vomited three times.

Her first emergency department visit revealed a heart rate of 105 beats per minute (elevated), abdominal tenderness with guarding (muscle tension indicating pain), and abnormal lab values including an elevated white blood cell count of 14,900 per microliter (normal range: 4,500-13,000) and low hemoglobin of 11.3 g/dL (normal: 12.0-16.0). Despite these findings, initial abdominal ultrasound showed no abnormalities.

Over the following weeks, her symptoms continued to worsen. She was unable to attend school regularly due to pain, and one week before final admission, abdominal pain woke her from sleep. By the day of admission to Massachusetts General Hospital, her pain episodes lasted 15 minutes, and she vomited five times.

Examination and Test Results

On final examination, the patient had a heart rate of 84 beats per minute, blood pressure of 113/78 mm Hg, and body mass index of 25.8. She was actively retching during examination and had diffuse abdominal tenderness with guarding but no rebound tenderness.

Laboratory tests showed concerning patterns:

• White blood cell count: 15,720 per microliter (elevated, normal: 4,500-13,000)
• Hemoglobin: 10.8 g/dL (low, normal: 12.0-16.0)
• Platelet count: 620,000 per microliter (elevated, normal: 150,000-450,000)
• Erythrocyte sedimentation rate: 32 mm/hr (elevated, normal: 0-19)

Computed tomography (CT) scan of the abdomen showed gastric contents but no obvious obstruction or other abnormalities initially noted. The radiologist later identified a mottled appearance in the gastric lumen that was consistent with a bezoar (a mass of foreign material).

Differential Diagnosis: What Could It Be?

The medical team considered multiple possible causes for her symptoms, systematically evaluating each possibility:

Common conditions initially considered:

• Constipation: Unlikely due to normal rectal exam and lack of abdominal distension
• Functional gastrointestinal disorders: Unlikely as symptoms woke her from sleep and worsened progressively
• Gastritis: Unlikely without typical risk factors like NSAID overuse or alcohol
• Postviral gastroparesis: Unlikely without preceding viral illness

Mechanical causes seriously considered:

• Malrotation with volvulus: Possible but unlikely with normal imaging
• Intussusception: Possible but unlikely with two normal ultrasounds
• Crohn's disease: Unlikely due to rapid symptom progression
• Gastric-outlet obstruction: Most likely given symptom pattern

The key diagnostic clue was the pattern of abrupt severe pain followed by vomiting that provided temporary relief, suggesting gastric outlet obstruction.

Final Diagnosis: Trichobezoar (Hairball)

Endoscopy revealed the definitive diagnosis: a large trichobezoar (hairball) extending from the stomach into the duodenum (the first part of the small intestine). This condition is known as Rapunzel syndrome when the hair mass extends into the small bowel.

Trichobezoars form when ingested hair accumulates in the stomach, resistant to digestion and peristalsis (digestive muscle movements). The hair becomes denatured by stomach acid and combines with food to form a matted mass that can grow large enough to cause obstruction.

This patient had a history of pica (eating non-food items) as a toddler, which raised suspicion for this type of condition, though there was no mention of current hair-pulling behavior initially.

Clinical Management: Treatment Approach

Treatment options for trichobezoars include enzymatic digestion, endoscopic removal, or surgical intervention. For large trichobezoars extending into the small intestine, surgical removal is typically necessary.

This patient required exploratory laparotomy (surgical abdominal incision) and gastrostomy (stomach opening) for removal. During surgery, the trichobezoar was confirmed to extend through the pylorus (stomach exit) into the duodenal bulb. The entire mass was successfully removed through the gastrostomy opening.

The surgical approach was chosen because:

• Enzymatic digestion is ineffective for hair-based bezoars
• Endoscopic removal was not feasible due to the size and extension into small bowel
• Laparoscopic surgery often fails for large bezoars due to prolonged operation time and infection risk

A literature review cited in the article shows that 93% of trichobezoar patients undergo laparotomy, with 99% success rates but 12% complication rates.

Psychiatric Aspects: Understanding the Root Cause

The most critical aspect of long-term management involves addressing the underlying psychiatric condition that leads to hair ingestion. Trichophagia (hair-eating) is most commonly associated with trichotillomania, a body-focused repetitive behavior disorder.

Trichotillomania affects 1-2% of the population worldwide and involves recurrent hair pulling resulting in hair loss, repeated attempts to stop the behavior, and clinically significant distress or impairment. Without treatment of the underlying psychiatric condition, bezoars are likely to recur.

This patient had a history of anxiety disorder and iron-deficiency anemia, along with family history of depression and anxiety in her father. These factors may have contributed to the development of hair-pulling and eating behaviors.

What This Means for Patients

This case offers several important lessons for patients and families:

For patients with unexplained gastrointestinal symptoms:

• Persistent abdominal pain with nausea/vomiting warrants thorough investigation
• Multiple emergency visits with normal initial tests don't necessarily mean nothing is wrong
• Complete medical history including psychiatric history is crucial for diagnosis

For patients with hair-pulling behaviors:

• Swallowing hair can lead to serious medical complications
• Seeking treatment for trichotillomania is essential for physical and mental health
• Be honest with doctors about these behaviors—they're medical conditions, not secrets to keep

For families supporting loved ones:

• Behavioral symptoms and physical symptoms are often connected
• Comprehensive care addressing both physical and mental health leads to best outcomes
• Recovery requires ongoing management to prevent recurrence

The case demonstrates how multidisciplinary care involving pediatricians, gastroenterologists, surgeons, and psychiatrists provides the best approach to complex medical conditions with behavioral components.

Source Information

Original Article Title: Case 36-2024: A 16-Year-Old Girl with Abdominal Pain

Authors: Garrett C. Zella, M.D., Ali Pourvaziri, M.D., M.P.H., Erica L. Greenberg, M.D., and Maureen M. Leonard, M.D.

Publication: The New England Journal of Medicine, November 21, 2024

DOI: 10.1056/NEJMcpc2402499

This patient-friendly article is based on peer-reviewed research from the Case Records of the Massachusetts General Hospital.