Rapunzel syndrome is the term for a trichobezoar (gastric 'hair ball') which has a tail-like extension into the small bowel through the pylorus causing gastric outlet obstruction.Human hair (especially long hair) is resistant to digestion as well as peristalsis. So it tends to stay in the stomach and over a period of time may form a large 'hair ball'. A trichobezoar may extend up to the pylorus, duodenum, or even jejunum. A part may break off into small bowel and cause small bowel obstruction.For discussion of other gastrointestinal foreign bodies, please see: bezoarsClinical presentationThe patient usually is an adolescent girl. The patient may have history of a psychiatric illness and occasionally a prior history of surgery may be present.The symptoms of Rapunzel syndrome is caused either by gastric outlet obstruction or its complications and includes:anorexia, bloating, early satietyweight lossvomiting immediately following mealsacute epigastric painpatchy hair loss seen in scalp hairComplicationsobstructive jaundicemechanical small bowel obstructionsmall bowel perforationperitonitisacute pancreatitis multiple complications of trichophagia included trichobezoars, malnutrition, intestinal obstruction, and ulceration with bleeding. One of the bouts of intestinal obstruction was associated with the superior mesenteric artery blocking the duodenum. Radiographic featuresAbdominal radiographdistended stomach shadow with an intragastric mottled gas pattern, outlined by fundal gas, which may resemble a food-filled stomachfree gas shadow under diaphragm may be seen on erect radiograph if bowel perforation is presentFluoroscopy: barium studiesmay show an intraluminal filling defect with mottled gas pattern without attachment to bowel wallover time the interstices of trichobezoar are filled with barium. This barium may remain for a considerable period of time and can be seen in delayed radiographs when the barium has exited the stomach and duodenumUltrasoundmay be seen as an echogenic mass with intense acoustic shadow seen within stomach and pylorus regioncomplex intraperitoneal free fluid if complicated by bowel perforationCTCT is the best imaging modality for showing the size and configuration of the trichobezoar and most accurately identifying its locationmay show an intragastric well-circumscribed inhomogenous mass consisting of 'mottled gas pattern' or 'compressed concentric rings' pattern due to the presence of entrapped air and food debrisbody of the mass in stomach while tail may extend to the duodenum or jejunumnormal stomach wall can be traced completely separate from the lesionno contrast enhancementmucosal edema and wall thickening may be seen in duodenum and jejunumintraperitoneal fluid with free gas can be seen if perforation is presentTreatment and prognosisMedical management is restricted to correction of anaemia and weakness. The treatment is essentially surgical. Laporotomy with extraction of bezoar is done with exploration of rest of the small bowel to look for detached bezoars. Small bowel segments showing extensive ulcerations and gangrene are resected.Psychiatric evaluation is suggested for underlying illness.Differential diagnosisAlthough the imaging features allow confident diagnosis of trichobezoars, depending on the investigative modalities, the differentials to be considered are:gastrointestinal tumour such as a GIST extending into the stomach lumenother type of bezoar (e.g. phytobezoar)