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Alopecia was noted on the right anterior scalp of a 53-year-old man who had been hospitalized for jaundice of 2 weeks' duration. The hairs in the affected area were broken off at various lengths (A). The patient, who was left-handed, repeatedly pulled individual hairs on his head; it was suspected that he occasionally swallowed them.He had a history of heavy alcohol consumption and end-stage liver disease.

During the hospital course, the patient complained of abdominal distention and pain. An abdominal radiograph revealed dilated loops of small bowel, consistent with small-bowel obstruction (B). Arun Swaminath, MD, of the University of California Medical Center in San Diego considered a trichobezoar as a possible cause of the obstruction. Failure of conservative management with nasogastric suction led to exploratory laparoscopy and enterotomy. A cause of the obstruction was not identified. The patient eventually died of multiorgan failure.

Trichotillomania is classified as an impulse-control disorder. The incidence is higher in alcoholic patients.1,2 The patch of hair loss is typically on the side opposite the dominant hand and contains broken hairs of varying size.3

Trichophagia, which is sometimes associated with trichotillomania, can lead to the formation of a trichobezoar in the GI tract.The best way to identify and treat a bezoar is via upper endoscopy. An upper GI barium swallow can also identify a bezoar. Complications of trichobezoars include intestinal obstruction, gastric ulcer, and gastritis. Migration of a gastric bezoar distally leads to small-bowel involvement.4

Refer patients with trichotillomania to a psychiatrist for counseling, habit reversal therapy, and medical management.5 Selective serotonin reuptake inhibitors are the treatment of choice for these patients. *


REFERENCES:1. Fontenelle LF, Mendlowicz MV, Versiani M. Impulse control disorders in patients with obsessive-compulsive disorder. Psychiatry Clin Neurosci. 2005;59:30-37.2. Lejoyeux M, Feuche N, Loi S, et al. Study of impulse-control disorders among alcohol-dependent patients. J Clin Psychiatry. 1999;60:302-305.3. Papadopoulos AJ, Janniger CK, Chodynicki MP, Schwartz RA. Trichotillomania. Int J Dermatol. 2003;42:330-334.4. Erzurumlu K, Malazgirt Z, Bektas A, et al. Gastrointestinal bezoars: a retrospective analysis of 34 cases. World J Gastroenterol. 2005;11:1813-1817.5. Salaam K, Carr J, Grewal H, et al. Untreated trichotillomania and trichophagia: surgical emergency in a teenage girl. Psychosomatics. 2005;46:362-366.
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