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Trichobezoar presenting with the 'comma sign' in Rapunzel Syndrome: a case report and literature review

S Dindyal1, NJ Bhuva2*, S Dindyal3, MJ Ramdass4 and V Narayansingh5

Author Affiliations

1 Royal Cornwall Hospital NHS Trust, South West England, UK

2 Imperial College Healthcare NHS Trust, London, UK

3 Plymouth Hospital NHS Trust, South West England, UK

4 South East Thames NHS Trust, London, UK

5 General Hospital, Port-of-Spain, Trinidad, West Indies

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Cases Journal 2008, 1:286  doi:10.1186/1757-1626-1-286

Published: 30 October 2008



Rapunzel Syndrome is an uncommon presentation of trichobezoar, involving strands of swallowed hair extending as a tail through the small intestine, beyond the stomach. This was first described in 1968 and until 2003 only thirteen cases have been reported.

Case Presentation

A 55-year old man of East Indian descent presented to the surgical team via the emergency department in Trinidad, West Indies, with an acute abdomen and small bowel obstruction. He had a recent psychiatric history and patchy alopecia as well as a family history of schizophrenia. A supine abdominal radiograph revealed a small bowel obstruction as well as an unusual air shadow in the left hypochondrium in the region of the duodeno-jejunal flexure associated with the stomach bubble, which resembled a 'comma'. At laparotomy, the stomach and third part of the duodenum were distended and contained a large mass of dark, foul-smelling hair that occupied the stomach, crossed the pylorus and extended into the small bowel. A retroperitoneal perforation of the third part of duodenum was found and repaired. The large trichobezoar was removed via a gastro-enterotomy and the patient made a slow, but complete recovery.


We wish to report another case of Rapunzel Syndrome and describe an unusual radiologic sign associated with a retroperitoneal perforation of the third part of duodenum – the comma sign. To the best of our knowledge this is the first reported case of a spontaneous retroperitoneal perforation of the third part of duodenum associated with Rapunzel Syndrome.