Doctors Spent 15 Hours Shaving Down a Giant Hairball Inside a 7-Year-Old Girl’s Stomach to Avoid Surgery

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The case, published Oct. 1 in Frontiers in Medicine by a team from the Xiaolan Clinical Institute of Shantou University Medical College in Zhongshan, describes a giant gastric trichobezoar, the medical term for a hairball made of swallowed hair. What made this one so stubborn was not just its size. Abundant cotton threads woven through it resisted nearly everything the doctors tried.

Large hairballs like this are usually removed with surgery. After doctors counseled the family, they declined an operation to open the stomach, so the team set out to remove the mass through an endoscope instead.

According to the report, the girl had about a week of upper-abdominal pain and an uncomfortable feeling of fullness after meals. She was also fatigued, with pale lips and inner eyelids.

An exam turned up a firm mass in her upper abdomen that made her belly visibly uneven. Blood work showed iron-deficiency anemia, with hemoglobin at 7.7 g/dL, along with low protein levels and a weakly positive test for hidden blood in her stool. Fatigue and pale skin are classic signs of iron-deficiency anemia, and bleeding in the digestive tract is one recognized cause.

Her history helped explain the rest. The girl had been eating hair, a behavior called trichophagia, since age 2. Her family reportedly stopped her whenever they caught it and believed she had quit in recent years, but she had never had formal psychiatric care or follow-up to confirm that.

A contrast-enhanced CT scan showed a mass inside the stomach “suspicious for a foreign body or trichobezoar, without evidence of extension beyond the stomach.” Endoscopy confirmed it. The hairball was coated in thick mucus, firm yet elastic, and densely packed with hair, food debris, and abundant cotton thread. The stomach lining where it had been lodged showed patches of erosion and ulceration.

The team worked in a single session under general anesthesia, with two endoscopists taking turns. The first approach, using standard foreign-body tools, went badly.

Grasping forceps could pull out only “a few hairs at a time, resulting in extremely low efficiency,” the authors wrote. A wire snare could not get a grip on the bezoar’s hard, smooth surface. During those first eight hours, forceps grasping and snare electrocoagulation had limited effect.

In their review of earlier reports, the authors found that open surgery accounted for roughly 65% of treated cases and laparoscopic surgery for about 22%. Successful endoscopic removal was reported in only about 13.8%. Failure rates for endoscopic techniques remain high, the authors noted, especially for large hairballs containing cotton thread.

Instead of stopping, the team changed tactics. They switched to an electrosurgical knife of the kind used in endoscopic submucosal dissection, a technique normally used to remove precancerous or cancerous growths from the digestive tract lining. They set it to a hybrid cutting and coagulation mode at a maximum of 80 watts. Lower settings of 40 to 60 watts and a pure cutting mode, had not worked on the cotton fibers.

They held the knife at a 30 to 45 degree angle and shaved the surface tangentially, one layer at a time. Saline was dripped in intermittently to create a fluid cushion between the bezoar and the stomach wall and keep the view clear. After each pass, forceps tore away the loosened material.

The final piece of the strategy protected the girl’s esophagus. A transparent cap was fitted to the tip of the endoscope, and each fragment was pulled into the cap before the scope was withdrawn. The endoscope, cap, forceps, and fragment came out together as one unit, shielding the esophagus from jagged edges on the way up.

This second phase took about six more hours. On reinspection, the doctors found “no significant gastric mucosal injury, cardia laceration, or esophageal abrasion.” The girl had a mild sore throat afterward that cleared on its own. She went home four days after the procedure, and at an eight-week check her symptoms had fully resolved, and her appetite had improved.

The authors say none of the earlier endoscopic methods dealt with a hairball packed with cotton threads.

Their conclusion is hedged: “With strict patient selection, multidisciplinary teamwork, and adequate expertise and equipment, endoscopic treatment may offer a minimally invasive alternative to the surgical removal of giant gastric trichobezoars in selected pediatric cases.”

They also acknowledge that “the short follow-up period (8 weeks) and the prolonged procedure duration limit the conclusions that can be drawn regarding general safety, efficacy, and recurrence prevention.” The technique requires specialized equipment, skilled endoscopists, and surgical backup. As a single case, it does not show that endoscopy should replace surgery for most patients.

The underlying behavior remains the bigger unknown. The girl was referred to a psychiatric clinic after discharge, but that assessment had not been completed when the report was written, so the authors could not say whether the hair-eating had been addressed or how likely a recurrence is.

Hair eating is often tied to trichotillomania, or hair-pulling disorder. Cleveland Clinic notes that about 1 to 2 of every 10 people with trichotillomania eat their hair, which can lead to hairballs that block the stomach or intestine. The main treatment for the pulling is habit reversal therapy. When a hairball extends from the stomach into the small intestine, doctors call it Rapunzel syndrome; this girl’s hairball stayed within her stomach. Parents who notice a child repeatedly eating hair should raise it with a pediatrician.

It is a mass of swallowed hair that collects in the digestive tract, most often the stomach. When it extends from the stomach into the small intestine, doctors call it Rapunzel syndrome. In this case, the hairball stayed within the stomach.

It was large, smooth, firm, and elastic, and it was woven with abundant cotton threads. Forceps pulled out only a few hairs at a time; the snare could not grip it, and lower-power electrosurgical settings barely affected the cotton.

Surgery is the usual treatment for giant hairballs, but after counseling, the girl’s family declined an operation to open her stomach. The team then attempted endoscopic removal with predefined criteria for stopping.

They shaved the mass in thin layers with a high-power electrosurgical knife, tore loose pieces away with forceps, and pulled each fragment into a clear cap on the endoscope tip, so it would not scratch the esophagus on the way out.

Is endoscopy now the preferred treatment for giant hairballs?

No. Surgery remains the mainstream treatment for large trichobezoars, and the authors say their approach may suit only selected children treated at centers with the right expertise and equipment. This report describes one patient.

It can if the hair-eating continues. That is why the girl was referred for psychiatric evaluation, which had not been completed at the time of publication.