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CHICAGO, Dec. 28 -- It's not widely known that humans -- like cats -- can develop hairballs.

All they have to do is eat hair -- their own, someone else's, or in one reported case, the hair from dolls -- but the condition, known as trichophagia, is relatively rare.

So when two physicians from Rush University Medical Center reported extracting a 4.5-kilogram hairball from an 18-year-old woman earlier this year, the prevailing reaction was surprise and to some degree amusement.

But the condition is far from benign. Unlike cats, humans who eat hair can't regurgitate it and, in the worst cases, trichophagia can end in death.

In the Rush case -- reported in the Nov. 22 issue of the New England Journal of Medicine -- the outcome was more positive: After surgery, the woman was eating normally within a few days and soon began to recover some of the 18 kilograms she had lost.

And she reported she had stopped eating her hair, according to Ronald Levy, M.D., and Srinadh
Komanduri, M.D.

The bezoar, they reported, filled the entire stomach and measured 15" x 7" x 7". The original plan had been to extract it by laparoscopy, but the procedure was converted to open surgery, which was successful.

A 1999 case was less positive. Seventeen-year-old Rachel Haigh died in Conquest Hospital in Hastings, England after surgery to remove a trichobezoar that came in at 480 cubic inches.

According to reports, Haigh died of internal bleeding after surgery to remove the hairball.

Trichophagia is a subclass of trichotillomania -- or hair-pulling -- which was recognized by the American Psychiatric Association as a distinct disorder in 1987.

The prevalence of trichotillomania is estimated at between 0.6% and 1.6%. Of those who have the condition, about 30% will eat their hair and only about 1% of those will eventually need surgical removal, according to Andrés Martin, M.D., and colleagues at Yale University School of Medicine.

In 2005, Dr. Martin and colleagues reported the case of a seven-year-old girl who had what is called Rapunzel syndrome -- the bezoar was so large it extended out of the stomach through the distal end of the duodenum.

About half a dozen such cases were reported worldwide in 2007.

In this case, Dr. Martin and colleagues reported, the girl had begun by chewing her dolls' hair at the age of three. She later started chewing her own hair and also her mother's, obtained from the parent's hairbrush.

The case came to their attention when, during a routine annual check-up, the child's pediatrician detected a non-tender palpable mass in the girl's stomach.

A CT scan showed the stomach almost filled with the mass and a gastrostomy revealed a bezoar that was 45 centimeters long and eight centimeters in diameter.

After the surgery and psychiatric counseling, Dr. Martin and colleagues said, the child appears to have stopped hair-pulling and hair-eating.

Trichobezoars are "nearly impossible" to diagnose with simple X-rays, Dr. Martin said. Ultrasound has been shown to be effective, although other conditions -- including a neuroblastoma, abscess, or fecal material -- can have a similar appearance, he noted, adding that abdominal CT with contrast can diagnose 97% of trichobezoars.

The problem with hair is that it is smooth, which means it doesn't move through the digestive system through peristalsis and becomes trapped in the mucosa. Over time, very large masses can accumulate.

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