(044) Functional Abdominal Pain or Trichobezoar? A Case Report of Concealed Trichophagia in an Adolescent

Presenting Author(s)

CH

Camila Haynes, MD

Fellow
University of Illinois Chicago
Chicago, Illinois

Co-Author(s)

Paloma Reinoso, MD

Fellow
University of Illinois Chicago
Chicago, Illinois
EC

Elizabeth A. Charney, MD

Assistant Professor of Psychiatry
University of Illinois Chicago
Chicago, Illinois

Disclosure(s):

Camila Haynes, MD: No financial relationships to disclose

Abstract:

Background: Trichophagia and trichotillomania are often underdiagnosed, particularly in children and adolescents. It is estimated that around 20% of individuals with trichotillomania engage in trichophagia (Grant, 2016). A rare, but serious and potentially fatal complication of this is the formation of a trichobezoar. Trichobezoars can impair gastrointestinal absorption of iron, potentially leading to iron deficiency anemia. Previous case reports have postulated that primary iron deficiency anemia could contribute to trichophagia, a form of pica (Gruenstein, 2020).

Case Summary: A 13-year-old female with a known history of post-traumatic stress disorder and major depressive disorder presented to the emergency department (ED) for acute abdominal pain, nausea, and vomiting. Abdominal pain with weight loss had been ongoing for six months with no etiology previously determined. Iron deficiency anemia was identified and treated with iron infusions during the four months before ED visit. Dermatology also diagnosed alopecia areata one month earlier, prescribing topical steroids. In the ED, she underwent imaging which demonstrated a large mass in her duodenum. She was admitted for an exploratory laparotomy which revealed a 19.2 x 15.2 x 8.3 cm trichobezoar. She received three iron transfusions while hospitalized due to persistent iron deficiency anemia. Consultation liaison (CL) pediatric psychiatry service was consulted to facilitate parental awareness of trichotillomania and provide recommendations for further management. CL recommended further titration of Sertraline, previously started by primary care. Ambulatory follow up with child and adolescent psychiatry was facilitated. She showed clinical response to Sertraline 100 mg daily and n-acetylcysteine 1200 mg daily in the outpatient setting.

Discussion: This case illustrates the previously described association of trichotillomania with iron deficiency anemia. One diagnostic challenge evident in this case was that despite previous encounters with several clinicians including psychiatrists and a therapist, psychosocial concerns and shame had prevented the patient’s disclosure of trichophagia. Management of psychiatric co-morbidities can help prevent recurrence of trichobezoar. Although many studies have been conducted in adults, limited clinical trials for treatment of hair pulling disorders in adolescents exist so there is insufficient evidence to determine best practices (Hoffman, 2021). Further research of pharmacological management of trichotillomania in pediatric populations is necessary.

Implications: While the formation of a trichobezoar is rare, given its associated risk of morbidity and mortality, awareness by CL psychiatrists and child psychiatrists regarding assessment for trichotillomania and trichophagia is warranted. Special consideration for screening should be considered for adolescents with co-morbid psychiatric conditions with a history of abdominal pain and iron deficiency anemia.

References:

Grant JE, Chamberlain SR. Trichotillomania. Am J Psychiatry. 2016;173(9):868-874. doi:10.1176/appi.ajp.2016.15111432

Gruenstein D, Levitt J, Abittan B. Trichotillomania due to pica in a 23-month-old patient with concomitant iron deficiency anemia and lead poisoning. JAAD Case Rep. 2020;7:91-92. Published 2020 Nov 19. doi:10.1016/j.jdcr.2020.11.010

Hoffman J, Williams T, Rothbart R, et al. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev. 2021;9(9):CD007662. Published 2021 Sep 28. doi:10.1002/14651858.CD007662.pub3

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: The case reports features a Hispanic female and illustrates a delayed recognition of symptoms, with these symptoms possibly being dismissed as somatization. The dismissal of symptoms may be attributable to racial bias. Additionally, this submission includes trainee co-authors that are underrepresented minorities in medicine (Dr. Haynes is Black-Caribbean, Dr. Reinoso is Latina-Peruvian).