A hairy situation

One of the most interesting cases that I saw during my psych rotation (which, by the way, ended on Friday with the NBME miniboard*) was a pediatric patient who presented with abdominal pain and an episode of vomiting. Some sort of scan (not sure if it was a CT or MRI) revealed a mass that was about the size of two footballs, which could be easily felt when palpating the abdomen. The size could be estimated by percussing and by using the scratch test, too.

When they figured out what it was, they consulted us in our psychiatry dungeon (psych & behavioral health is in the basement of the hospital.) It was HAIR. The patient's scalp had a few bald spots, and questioning revealed that she was pulling out her hair and chewing on it. Rapunzel syndrome at its finest. They told us about bezoars (glorified human hairballs) in GI pathology last year, and then followed up by telling us that we'd never ever see one. The surgeon that removed this patient's bezoar hadn't seen one. And the images that were taken after surgery were amazing - the patient's stomach was so full of hair that the bezoar looked like a cast of a stomach made of hair after it was removed. Her intestines had to be scoped 70 feet to remove all of the strands.

I went on a consult with the child psychiatrist, when the patient was a few days post-op, and we couldn't find any other OCD-type behaviors, so I don't know what was going on. And I expected her to look malnourished, because she had been doing this for at least two years and, judging by the size of the resected hairball, should have definitely had obstruction problems (she didn't until the week she came to the hospital.) She said that she drank 1 gallon of chocolate milk every day, which provided her with enough calories, I guess - but milk also curdles and adds to the mass. Nice, huh?

There's some pictures and other interesting information on trichotillomania (hair pulling) here - I don't want to post the pictures, lest I make someone spew on their monitor!

*Each rotation culminates in an NBME (National Board of Medical Examiners) miniboard exam - which I'll talk about in a separate post, because the hairball? Deserves to stand on its own.