Pediatric Annals

CME Article 

Adolescent Abdominal Pain with a Twist

Meera S. Beharry, MD, FAAP

Abstract

CME Educational Objectives

  1. Delineate the DSM-IV criteria for trichotillomania.

  2. Identify the clinical findings in patients with trichotillomania.

  3. Describe the presenting symptoms found in patients with a trichobezoar and outline the complications associated with this disorder.

A 17-year-old young woman presented to her pediatrician for evaluation of abdominal pain and increased eructation (belching). She described the pain as a burning or boring sensation that became worse with eating. Review of her dietary history revealed no clear cause of the pain. The patient reported normal bowel movements occurring every day or every other day. She denied the presence of blood or mucous in her stool. Past medical history was positive for a history of alopecia that was first noted 3 years ago. Work-up for a cause of the alopecia was negative, and the alopecia was determined to be related to stress. Menstrual history included menarche at age 12 years, with normal menses occurring every month and lasting 5 days. Family history was negative for gastrointestinal disorders, such as inflammatory bowel disease and irritable bowel syndrome, and for autoimmune disorders, such as systemic lupus erythematosus. The patient’s physical examination showed an anxious, thin young woman who was in no apparent distress. Oropharynx was normal and without lesions, bowel sounds were normo-active, and abdominal examination revealed a scaphoid abdomen without organomegaly or palpable masses.

Abstract

CME Educational Objectives

  1. Delineate the DSM-IV criteria for trichotillomania.

  2. Identify the clinical findings in patients with trichotillomania.

  3. Describe the presenting symptoms found in patients with a trichobezoar and outline the complications associated with this disorder.

A 17-year-old young woman presented to her pediatrician for evaluation of abdominal pain and increased eructation (belching). She described the pain as a burning or boring sensation that became worse with eating. Review of her dietary history revealed no clear cause of the pain. The patient reported normal bowel movements occurring every day or every other day. She denied the presence of blood or mucous in her stool. Past medical history was positive for a history of alopecia that was first noted 3 years ago. Work-up for a cause of the alopecia was negative, and the alopecia was determined to be related to stress. Menstrual history included menarche at age 12 years, with normal menses occurring every month and lasting 5 days. Family history was negative for gastrointestinal disorders, such as inflammatory bowel disease and irritable bowel syndrome, and for autoimmune disorders, such as systemic lupus erythematosus. The patient’s physical examination showed an anxious, thin young woman who was in no apparent distress. Oropharynx was normal and without lesions, bowel sounds were normo-active, and abdominal examination revealed a scaphoid abdomen without organomegaly or palpable masses.

A 17-year-old young woman presented to her pediatrician for evaluation of abdominal pain and increased eructation (belching). She described the pain as a burning or boring sensation that became worse with eating. Review of her dietary history revealed no clear cause of the pain. The patient reported normal bowel movements occurring every day or every other day. She denied the presence of blood or mucous in her stool.

Past medical history was positive for a history of alopecia that was first noted 3 years ago. Work-up for a cause of the alopecia was negative, and the alopecia was determined to be related to stress. Menstrual history included menarche at age 12 years, with normal menses occurring every month and lasting 5 days. Family history was negative for gastrointestinal disorders, such as inflammatory bowel disease and irritable bowel syndrome, and for autoimmune disorders, such as systemic lupus erythematosus.

The patient’s physical examination showed an anxious, thin young woman who was in no apparent distress. Oropharynx was normal and without lesions, bowel sounds were normo-active, and abdominal examination revealed a scaphoid abdomen without organomegaly or palpable masses.

She was started on empiric treatment with an H2 blocker for gastritis. At follow-up a few months later, she reported modest improvement in her symptoms but was noted to have a 7-lb weight loss. The patient was surprised by this. She denied intentional weight loss through exercise, induced emesis, or laxative or diuretic use. Upon further questioning, her mother reported that the patient was eating less than usual. When asked specifically about this, the patient reported that she did not feel hungry.

Further social history was obtained. The patient reported that she was happy living at home with her mother, father, and older sister. She was in 12th grade and doing well in all her classes, many of which were advanced placement classes. She was unsure of her future career plans. Her favorite activities were reading magazines and going to the mall with friends. She reported having experimented with alcohol but denied ever having been drunk or using other substances. She denied sexual activity or sexual abuse and stated she was attracted to males. She reported being stressed about not having a career plan, applying to college, and keeping up with her advanced coursework. She denied suicidal or homicidal ideation.

Because of concerns for a possible eating disorder, she was referred to a therapist and prescribed a 2,000-kcal/d meal plan. At follow-up 1 month later, she had not yet seen a therapist but she had lost another 8 lbs. She had continued to take the H2 blocker but again reported increased eructation. She stated she was unable to follow the 2,000-kcal/d meal plan. Physical examination confirmed that she had had lost weight, but her vital signs and physical examination were otherwise normal.

Her mother was very concerned about her daughter’s organic pathology. Complete blood count (CBC), blood chemistry, and erythrocyte sedimentation rate (ESR) were normal. Prior to her next appointment, the patient was reading a magazine and found an article about a lethal medical condition and realized that it could be the cause of her symptoms. Panic-stricken, she informed her mother, who then called the pediatrician. An upper gastrointestinal study was obtained, the results of which prompted a surgical referral and confirmation of the diagnosis (Figure 1).

Upper GI series of patient with trichobezoar. .Published with permission from LearningRadiology.com

Figure 1. Upper GI series of patient with trichobezoar. .Published with permission from LearningRadiology.com

Diagnosis

Trichotillomania with Trichophagy and Giant Trichobezoar

Discussion

The development of a trichobezoar is a rare and potentially life-threatening complication of trichotillomania, which is an impulse control disorder characterized by the persistent and excessive pulling of one’s own hair. The term “trichobezoar” derives from the Greek word for hair and the Arabic word “bazahr,” which means protection from poisoning. A bezoar is an aggregation within the gut of indigestible foreign matter, which is repeatedly ingested over a period of time. Bezoars can be broadly classified as trichobezoars (hair ball), phytobezoars (food ball), and miscellaneous (such as pharmacobezoar, a collection of drugs).1

The term “trichotillomania” was coined in 1889 by the French dermatologist, Hallopeau.2 According to the DSM-IV, the features of this condition are recurrent pulling out of one’s hair, resulting in noticeable hair loss and clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is also an associated increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, followed by pleasure, gratification, or relief when the act of pulling out the hair occurs. However, the disturbance should not be better accounted for by another mental disorder or caused by another medical condition. Currently, trichotillomania is classified as an impulse control disorder, but there is an ongoing debate about whether it would be better classified as an anxiety or obsessive-compulsive disorder.2,3

Prevalence estimates range from a point prevalence of 4% to a lifetime prevalence of 10% among the general population.2–4 Anonymous surveys among college students have revealed that 0.6% met the criteria for trichotillomania and another 2.5% met partial criteria.4 Onset is generally in the prepubertal years, peaking between ages 9 and 13 years. Although there is an equal prevalence between the genders in childhood, the diagnosis is more common in women in adulthood.

Clinical characteristics of alopecia caused by trichotillomania are hairs that are irregularly shaped with angular borders and of varying lengths, hair loss is sometimes biased to the side of handedness, and affected areas are never completely bald.2,4,5 The differential diagnosis includes but is not limited to alopecia areata, tinea capitis, traction alopecia, female pattern hair loss (androgenetic alopecia), and teloegen effluvium.4,5 Patients often pull hair from the scalp; however, pulling hairs from eyebrows and eyelashes has also been reported. Other areas of hair pulling include the pubic, perianal, nasal, ear, and abdominal areas.4

Of patients with trichotillomania, approximately one half practice associated oral behaviors such as touching or tickling their lips or nostrils with the hair, one third bite off the root of the hair, and 5% to 18% engage in trichophagy (as our patient did). Many patients report spending over 1 hour a day engaged in hair pulling, with 95% reporting episodes of bingeing (ie, pulling hair for several hours at a time).4

Hypotheses of etiology include biochemical dysfunction including serotonin deficiency, structural brain abnormalities that are based on MRI findings of abnormalities in the lenticulate gyrus, abnormal brain metabolism due to the finding of high glucose metabolic rates in the global, bilateral, cerebellar, and right superior parietal areas, or endogenous opiate activity.3,4

Trichotillomania with trichophagy can result in the rare, but potentially fatal complication of trichobezoar, as in our patient (Figures 2 and 3). Patients with trichobezoar often are asymptomatic but can present with anorexia due to early satiety, weight loss, anemia, gastrointestinal disturbances, and abdominal pain once the bezoar has progressed to a large size.1 Complications of trichobezoar can include Rapunzel syndrome, which involves extension of the trichobezoar throughout the intestine, perforation of the intestine, and peritonitits.1

Trichobezoar being removed from patient.Photo courtesy of Donald B. Shaul, MD. Reprinted with permission.

Figure 2. Trichobezoar being removed from patient.Photo courtesy of Donald B. Shaul, MD. Reprinted with permission.

Trichobezoar after removal.Photo courtesy of Donald B. Shaul, MD. Reprinted with permission.

Figure 3. Trichobezoar after removal.Photo courtesy of Donald B. Shaul, MD. Reprinted with permission.

Pharmacologic treatment of tricho tillomania includes use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, venlafaxine, lithium, and naltrexone.3,7 Behavioral therapy with various treatment strategies, including habit reversal therapy, relaxation training, hypnosis, and elimination of comorbid behavior, have also been employed.3 Recent comparisons of pharmacotherapy and psychotherapy have demonstrated that habit reversal therapy is superior to treatment with clomipramine and that treatment with SSRIs was not more effective than treatment with placebo.7

Many patients with trichotillomania have difficulty finding providers of psychotherapy, social support, and cosmetic care. The Trichotillomania Learning Center has compiled lists that address these needs for patients and providers. This information can be accessed at their website: www.trich.org/index.asp.8

References

  1. Sehgal VN, Srivastava G. Trichotillomania +/− Trichobezoar revisited. J Eur Acad Dermatol Venereol. 2006; 20(8):911–915.
  2. Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review. Pediatrics. 2004;113:e494–e498. doi:10.1542/peds.113.5.e494 [CrossRef]
  3. Woods DW, Flessner C, Franklin ME, et al. Understanding and trichotillomania: what we know and what we don’t know. Psychiatr Clin North Am. 2006;29(2):487–501. doi:10.1016/j.psc.2006.02.009 [CrossRef]
  4. Ellis C, Roberts HJ. Anxiety disorder, trichotillomania. Available at: www.emedicine.com/ped/TOPIC2298.HTM. Accessed Feb. 1, 2011.
  5. Shapiro J. Hair loss in women. N Engl J Med. 2007;357(16):1620–1630. doi:10.1056/NEJMcp072110 [CrossRef]
  6. Dell’Osso B, Altamura AC, Allen A, Marazziti D, Hollander E. Epidemiologic and clinical updates on impulse control disorders: a critical review. Eur Arch Psychiatry Clin Neurosci. 2006;256(8):464–475. doi:10.1007/s00406-006-0668-0 [CrossRef]
  7. Bloch MH, Landeros-Weisenberger A, Dombrowski P, et al. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry. 2007;62(8):839–846. doi:10.1016/j.biopsych.2007.05.019 [CrossRef]
  8. The Trichotillomania Learning Center. Available at: www.trich.org/index.asp. Accessed April 5, 2012.

Authors

Meera S. Beharry, MD, FAAP, is Assistant Professor of Pediatrics and Adolescent Medicine, Division of Adolescent Medicine, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY.

Disclosure: Dr. Beharry has disclosed no relevant financial relationships.

Address correspondence to: Meera S. Beharry, MD, FAAP, Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 690, Rochester, NY 14642; fax: 585-242-9733; email: meera_beharry@urmc.rochester.edu

10.3928/00904481-20120525-11

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