Rare case highlights need for vigilance in diagnosing asymptomatic Rapunzel syndrome in adolescents

Medical reports from 2026 reveal that adolescents with unusual gastrointestinal symptoms may hide severe trichobezoars despite lacking typical signs, urging clinicians to consider this rare diagnosis even in asymptomatic cases.

A case report published on 24 August 2026 is urging doctors not to rely on the usual tell-tale signs before ruling out Rapunzel syndrome, after surgeons in Albany, New York removed a stomach-shaped mass of hair from a 16-year-old girl who had no obvious bald patches and no documented psychiatric disorder. According to the Journal of Medical Case Reports paper, the blockage stretched from her stomach into the duodenum and had to be removed in theatre because it could not be reached with a scope. Medical Daily, which reviewed the pathology details, said the mass weighed about 1,500g and measured 21.2cm by 15.8cm by 7.7cm, with a tail roughly 20cm long running through the first three parts of the duodenum.

What made the Albany case striking was how little outward warning there had been. After surgery, the girl said she had been pulling and swallowing her own hair for about two years, but only around once a week. Medical Daily reported that she took about three hairs at a time, changed the place on her scalp, and sometimes snapped the strand rather than pulling from the root, helping to conceal the behaviour from her family. The same report said she had no visible thinning, denied trauma or abuse, and had been living in a stable home environment. She also had a history of migraines with cyclic vomiting, which may have made a gastrointestinal explanation seem more likely than a concealed repetitive behaviour. The Albany team discharged her on sertraline 25mg and referred her for cognitive behavioural therapy.

The broader lesson is that the dramatic surgical finding sits at the far end of a much more common disorder. The Albany authors said their patient had “remained completely asymptomatic until complete blockage of her GI tract”. In the same paper, they noted that only a small minority of people who swallow hair go on to develop a trichobezoar, the medical term for a compacted hair mass in the digestive tract. HCN/MDLinx, in a medical brief summarising the literature around a separate case, said the symptoms can include bad breath, abdominal pain, nausea, vomiting and even peritonitis, and that nutritional problems such as iron or vitamin B12 deficiency may also appear. Medical Daily reported that the Albany patient had low iron, worsening halitosis, fatigue and altered bowel habits before the obstruction was discovered.

A second 2026 report points in the same direction. Writing in Cureus on 18 June 2026, surgeons in Puerto Rico described a 17-year-old girl with autism spectrum disorder whose guardian denied any history of trichotillomania or pica. She arrived after three weeks of diffuse abdominal pain, nausea and bilious, non-bloody vomiting. Imaging showed a large mass in the stomach and duodenum, while endoscopy confirmed a trichobezoar blocking passage into the pylorus. She ultimately required an open laparotomy, with one portion removed through the stomach and another extracted through the proximal jejunum. The authors said she was stable after surgery and warned that upper gastrointestinal symptoms in adolescents with neurodevelopmental disorders should not be dismissed simply because no one reports hair ingestion.

That diagnostic blind spot had already surfaced in a Massachusetts General Hospital case published in the New England Journal of Medicine on 20 November 2024. Popular coverage by VICE, HCN/MDLinx and Gizmodo said a different 16-year-old spent weeks with abdominal pain, nausea and vomiting, yet repeated CT scans, blood work and other tests were reported as normal. VICE said she was discharged after one round of negative investigations with pain relief, anti-sickness medication and treatment for a possible ulcer, only for the pain to continue. The diagnosis came when doctors finally performed an endoscopy and found a wad of matted hair extending from the stomach into the small bowel.

Accounts of the Massachusetts case added the sort of details that explain why these patients can bounce between services before anyone suspects a bezoar. Gizmodo said the teenager rated her pain at eight out of 10 and that it was bad enough to wake her at night. HCN/MDLinx said the initial work-up can be misleadingly bland, even when the eventual problem is a mechanical blockage. VICE described the endoscopic finding as a two-and-a-half-inch tangle hanging into the small bowel, while Gizmodo reported that the girl later had no lingering stomach pain a month after treatment.

Taken together, the cases suggest that absence of evidence is not evidence of absence. HCN/MDLinx said trichotillomania is thought to affect 1% to 2% of the global population, that 5% to 20% of those patients may engage in trichophagia, and that only a small fraction go on to develop trichobezoars. That helps explain why most clinicians will rarely, if ever, see Rapunzel syndrome itself. But it also means the disorder can hide in plain sight, especially when hair loss is diffuse, the patient is ashamed, or a pre-existing history of vomiting sends doctors looking in the wrong direction.

The Albany paper and the Puerto Rico report end up in much the same place: surgery can clear the obstruction, but it does not solve the behaviour that caused it. The Cureus authors said “Multidisciplinary surgical and psychiatric follow-up is essential to prevent recurrence.” For clinicians, the warning from both 2026 reports is plain: an adolescent girl with unexplained nausea, vomiting or abdominal pain may still have a trichobezoar even if her hair looks normal, her family has noticed nothing unusual, and she does not fit the expected psychiatric profile.