GI trichobezoars are extremely rare, and constitute 6% of all bezoars [3]. They are mostly seen in females in their teens with an unrevealed inciting psycho-social ailment [3, 4]. In our series, all four cases were female in the 10 to 14 years age group, with a history of trichotillomania and trichophagia. For all four cases, the parents were initially hesitant in sharing information about their children’s behavioural disorders suggestive of trichotillomania and trichophagia, but upon conciliation with the paediatric clinical psychologist, they revealed the information. There was no family history of any psychological problem in any of our cases, and all the patients showed average academic performance. We presume that in this age group shift from pre-teens to teens, there are numerous pressor factors that can incite such behavioural changes. These behavioural problems can be due to causes ranging from true psychiatric ailments or mental retardation to temporary pressor factors such as hormonal changes, academic pressures, childhood neglect, or any sudden emotional event [4, 9].

Clinical manifestation of GI trichobezoars depends upon its size and site [2, 3]. It may remain undiagnosed for years with non-specific signs and symptoms of abdominal pain, vomiting, and early satiety, till it grows to a size to present as a palpable lump in the abdomen with gastric outlet obstruction or its secondary complications such as GI bleeding, gastric erosion, perforation, and peritonitis [2, 3, 5, 6, 9,10,11,12,13, 19]. In addition, intussusception, obstructive jaundice, and pancreatitis have been reported in the literature as complications of unrecognized GI trichobezoar [5, 6, 13,14,15,16]. The rare presentation of trichobezoar is acute abdomen with intestinal obstruction secondary to concurrent or isolated trichobezoar masses in the small intestine [1, 2, 9].

Three cases in our series were of gastric trichobezoars who presented late with a palpable mass in the abdomen with features of gastric outlet obstruction, while one case presented with symptoms and signs of acute abdomen. History of thinning of hairs, trichotillomania, and trichophagia gave us a clue to the diagnosis in such cases.

A plain X-ray abdomen is a nonspecific aid in investigating cases of GI trichobezoars but gives useful information in clinically suspected cases of intestinal obstruction or peritonitis with GI perforation [2]. Diagnosis can be made with a CT scan and upper GI endoscopy [4, 19]. Though upper gastrointestinal endoscopy is considered gold standard [19], a CT scan abdomen, especially contrast-enhanced CT, is the preferred image study for the evaluation of suspected cases of gastric trichobezoar [2, 4]. Although small-bowel bezoars CT findings are nonspecific, it is superior to other radiological modalities for bezoars diagnosis and in suspected cases of small-bowel intestinal obstruction [2]. Diagnostic features of CT images of gastric trichobezoar are the appearance of hypodense and heterogenous mass with mesh-like pattern and mottled air pattern of interspersed air [2, 4]. It is also useful to detect concomitant gastric and small bowel bezoars [2]. In our case series, we did a CT scan abdomen in all cases, and it aided us in the diagnosis-making process and further surgical management.

Management of GI trichobezoar has two main elements; one is its surgical removal with the management of possible complications if any, and secondly, evaluation and management of any underlying psychiatric or social disorder to prevent its recurrence [1, 4, 19,20,21]. The reported recurrence rate in literature is 20% [22] and that underpins the need for periodic psychological assessment in follow-up clinics. Some literature reports an association between trichobezoar and pica [23], which is a compulsive disorder resulting in ingestion of inedible items. This calls for psychiatric evaluation and treatment in the management of trichobezoar cases.

We did laparotomy in all 4 cases, in three cases trichobezoars were removed through anterior gastrostomy while in the fourth case, enterotomy was done for the removal of small bowel trichobezoars. This fourth case was a rare presentation with subacute intestinal obstruction, where only isolated small bowel trichobezoars were found. Paediatric psychiatric consultation was also done in all the cases for assessment and management of the underlying psycho-social problems. Trichobezoar when being removed is potentially infective because of the prolonged time it takes in presentation and entrapment of food particles becoming rancid over time, extreme care was taken to prevent infection in each case. We isolated the part to be opened from the surrounding viscera by abdominal sponges and avoided spillage in the abdominal cavity. Before closing the abdominal wound, it was thoroughly cleaned with povidone and normal saline. We used broad-spectrum antibiotics in all cases. There were no wound infections in our series.

All four patients were later referred to the hospital’s clinical nutritionist for assessment to develop a suitable dietary plan as they were all lean and thin built.

In the literature review, removal of GI trichobezoars by endoscopic techniques or surgical (laparoscopic or open) has been described with varying success rates depending upon available resources, technical expertise, location, consistency, and size of bezoar [4, 24,25,26,27]. Gorter et al. [6], in a retrospective review of 108 cases of trichobezoars, evaluated the success rate of available management options and found that attempted endoscopic removal was not promising and was successful in only 5% of cases, 75% of attempted laparoscopies with different techniques were successful with reported advantages of better cosmesis, reduced hospital stay, whereas reported disadvantages were more spillage in the peritoneal cavity, more operative time, difficulty in assessing concurrent small bowel trichobezoars in cases of intestinal obstruction [4, 6]. Laparotomy was successful in 100% of cases and found the preferred mode of removal of large trichobezoars that allows careful examination of the entire gastrointestinal tract with less complication rate [4, 6, 19, 20, 24]. Other modalities of medical management and enzymatic degradation have been reported as ineffective in cases of trichobezoars [6, 9].