Endoscopic removal of a large gastric trichobezoar using a snare modified from a lithotripter to facilitate argon plasma coagulation

Trichobezoars, rare gastric bezoars made of hair, are most common in young girls with psychiatric disorders. They usually accumulate in the stomach and may extend into the small intestine, known as Rapunzel syndrome [1]. Patients often present with obstruction, bleeding, or perforation. Larger trichobezoars typically require surgery due to the challenges of endoscopic treatment [2] [3] [4]. Here, we report a successful endoscopic retrieval of a large gastric trichobezoar using a snare made from the core of a lithotripter to assist in argon plasma coagulation ([Video 1]).

Endoscopic removal of a large gastric trichobezoar using a snare created with a modified lithotripter to facilitate argon plasma coagulation in a 16-year-old girl.Video 1

A 16-year-old girl with autism presented with upper gastrointestinal obstruction. Endoscopy showed a large gastric trichobezoar mixed with string and plastic ([Fig. 1]). The trichobezoar extended from the gastric fundus to the pylorus, partially into the descending part of the duodenum ([Fig. 2]), making it too large for a polypectomy snare or lithotripter to encircle.

Fig. 1 Endoscopic image of a large gastric trichobezoar mixed with string and plastic in a 16-year-old girl.

Fig. 2 The trichobezoar is seen extending from the gastric fundus to the pylorus, with partial protrusion into the descending part of the duodenum.

To address this, we modified the lithotripter by cutting the core wire and forming loops at both ends to create a snare wire ([Fig. 3]). First, one loop was secured to the anterior gastric wall near the location of the trichobezoar using a titanium clip ([Fig. 4] a). An overtube was placed, and a polypectomy snare was positioned over the transparent cap before advancing the endoscope. The other loop was held with foreign body forceps and passed from the posterior wall of the stomach along the greater curvature, encircling the trichobezoar, until it converged with the loop fixed to the anterior wall ([Fig. 4] b, c). The snare was released to encircle the wire loop, and both loops were grasped with forceps ([Fig. 4] d, e). The forceps and snare were tightened, guiding the trichobezoar to the lower esophagus, and the endoscope was withdrawn ([Fig. 4] f). The other endoscope was inserted and argon plasma coagulation was applied along the snare wire to fragment the trichobezoar. By repeating the aforementioned steps, the trichobezoar was completely removed ([Fig. 5]).

Fig. 3 a Core of the lithotripter. b The lithotripter was modified by cutting the core wire and forming loops at both ends to create a snare wire.

Fig. 4 Endoscopic retrieval of the gastric trichobezoar. a One loop was secured to the anterior gastric wall near the trichobezoar using a titanium clip. b The second loop was grasped with foreign body forceps. c The loop was maneuvered around the base of the trichobezoar and joined with the loop fixed to the anterior wall. d The polypectomy snare was released over a transparent cap. e The two loops were grasped using foreign body forceps. f The forceps and snare were tightened, guiding the trichobezoar into the lower esophagus.

Fig. 5 The trichobezoar was completely removed following fragmentation.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Li Y, Lu J, Lei W. et al. A simple endoscopic treatment for large gastric bezoars: the guidewire and snare method. Endoscopy 2022; 54: E1058-E1059
• 2 Patil M, Gharde P, Shinde RK. et al. Rapunzel syndrome: diagnostic challenges and multidisciplinary treatment strategies. Cureus 2024; 16
• 3 Baek SG, Oh CH, Shin GY. et al. Endoscopic retrieval of a huge gastric trichobezoar using an electrosurgical knife. Endoscopy 2021; 53: E357-E358
• 4 Benatta MA. Endoscopic retrieval of gastric trichobezoar after fragmentation with electrocautery using polypectomy snare and argon plasma coagulation in a pediatric patient. Gastroenterol Rep 2015; 4: 251

Publication History

Article published online:
03 April 2025