A 14-year-old girl named Mali was admitted to my ward at the Sri Jayawardanapura General Hospital in Nugegoda, Sri Lanka, after months of suffering. She came from a remote district in Sri Lanka, where access to specialist medical care was limited. For nearly three months, she had struggled with persistent upper abdominal pain, repeated vomiting, poor appetite, and gradual weight loss. Her family had sought help from several doctors in her hometown, hoping the symptoms would settle with treatment. Yet nothing seemed to work. Her condition steadily worsened, eventually forcing her family to travel to Colombo in search of answers.
By the time Mali was admitted to the hospital, she looked frail and exhausted. She was pale, thin, and weak. Her mother later recalled how her once-active daughter had become quiet and withdrawn, unable to eat properly or enjoy daily life. The family feared something serious was hidden behind her mysterious illness.
The initial medical examination revealed dehydration and anemia. Surprisingly, examination of the abdomen did not reveal a clear cause for her distress. There was no obvious swelling or mass that could explain why she had become so unwell. A previous ultrasound scan of her abdomen had not revealed any abnormality. However, her symptoms pointed toward a blockage somewhere in the upper digestive tract.
A decision was made to perform an endoscopy, a procedure in which a thin camera is passed into the stomach to examine its interior. The expectation was to identify an ulcer, inflammation, or perhaps an obstruction caused by food or a tumor. But the procedure produced an unusual and unexpected finding.
The endoscope could not pass beyond the upper opening of the stomach because something blocked the passage. Through the camera, strands of hair were visible. This puzzling discovery raised suspicion that the obstruction might be caused by a tightly packed mass of swallowed hair.
At this stage, surgery became necessary.
During the operation, the surgeons discovered that Mali’s stomach was enlarged and severely obstructed. When they carefully opened the stomach, the cause of her illness became clear. Inside was a massive hairball, tightly packed and shaped like the stomach itself. The dark, compact mass occupied almost the entire stomach cavity.
The surgeons soon realized that the problem was even more unusual than expected. The hairball extended beyond the stomach into the first sections of the small intestine in the form of a tail. This extension into the bowel made the case exceptionally rare.
The entire mass was removed through an opening in the stomach. Once removed, the obstruction was relieved immediately. The stomach was then closed, and the operation was completed successfully.
Fortunately, Mali recovered well after surgery. Her appetite gradually returned, she gained strength, and her symptoms disappeared. What had appeared to be a mysterious wasting illness was solved by the discovery of an unusual condition that few people, even in medicine, encounter during their careers. The case was particularly significant because it represented the only reported example of this condition in Sri Lanka.
Understanding the Hair Ball
A hairball inside the stomach is medically known as a trichobezoar. The word comes from two parts: “tricho,” meaning hair, and “bezoar,” meaning a compact mass trapped in the digestive system. Bezoars can form from different materials such as plant fibers, undigested food, or medications. However, hair-related bezoars are among the rarest.
Hair cannot be digested by the human stomach. Unlike food, it resists the action of digestive juices. When swallowed repeatedly over time, strands of hair accumulate in the stomach because they are too slippery to be expelled through normal muscular contractions. Gradually, the hair becomes trapped, mixes with mucus and food particles, and forms a dense mass.
As more hair collects, the mass enlarges and begins to take the shape of the stomach itself. In severe cases, strands may extend beyond the stomach into the small intestine, forming a long tail. This condition is known as Rapunzel Syndrome, named after the fairy tale character famous for her long, flowing hair.
In Mali’s case, the hairball extended into the small intestine, making it an example of Rapunzel Syndrome.
A Hidden Psychological Condition
Many patients with trichobezoars have an underlying behavioral or psychological condition. The most common is trichophagia, a compulsive habit of eating hair. Often associated with this is trichotillomania, a disorder in which individuals repeatedly pull out their own hair.
These behaviors may remain hidden for years because patients are embarrassed or unaware that they are doing it. Families may not notice the habit, especially when it occurs in private. Children and adolescents are particularly vulnerable, as emotional stress, anxiety, or underlying psychological struggles may contribute to the behavior.
After surgery, it became important not only to treat the physical condition but also to prevent recurrence. Mali was therefore referred for psychiatric assessment and counseling. Her parents were advised to observe her closely and support her recovery.
With appropriate guidance and family involvement, she gradually overcame the behavior that had caused the problem.
Rare but Potentially Dangerous
Although uncommon, hairballs in the stomach can lead to serious complications if not recognized early. Patients often develop symptoms only after the mass has grown large enough to block the digestive tract. Common symptoms include abdominal pain, vomiting, poor appetite, weight loss, weakness, and anemia. Because these symptoms are nonspecific, diagnosis may be delayed.
If left untreated, a trichobezoar may cause bleeding, stomach ulceration, intestinal obstruction, or even perforation of the bowel. These complications can become life-threatening.
Most reported cases occur in adolescent girls, particularly between the ages of 12 and 14. Researchers believe that psychological and behavioral factors play an important role in this age group. Worldwide, only around 51 cases of Rapunzel Syndrome had been reported in the medical literature at the time this case was documented, with many originating from South Asian countries.
Life Beyond the Illness
The true success of treatment lies not only in removing the physical problem but also in restoring a patient’s life.
Following surgery and psychiatric support, Mali made a full recovery. Over time, she regained weight, returned to normal activities, and moved beyond the frightening illness that had once dominated her life.
Today, she is a healthy adult, married, and the mother of a child. She leads an ordinary life, free from the symptoms and hidden behaviors that once threatened her health.
Her story serves as a reminder that uncommon illnesses can hide behind common symptoms. It also highlights the importance of persistence in diagnosis and the need to consider both physical and psychological aspects of care.
