Introduction: Trichobezoar is a rare (<1%) pathology, especially in the pediatric age group, causing gastric outlet obstruction in delayed presentation. Refeeding syndrome is a well-described but often forgotten condition that affects chronic malnutrition. Although Trichobezoar with Rapunzel syndrome has been reported by many in the literature, refeeding syndrome occurring in the postoperative period in these patients is extremely rare. To the best of our knowledge, our case of an 11-year-old girl is the first such case to be reported in the literature.

Methods: After 3 years of pain in the abdomen and vomiting, a trichobezoar was removed successfully in toto with its tail (Rapunzel Syndrome) of length ~90cm, complete specimen length was 125 cm and the weight was 1 kg. On the 4th POD, orals were allowed and the next day, she developed generalized tonic-clonic seizures (GTCS) with up rolling of eyes with gradual onset generalized edema and high output abdominal drain. The refeeding syndrome was suspected and confirmed biochemically. TPN and Anti-epileptics started and she improved. But on the 12th POD, she had abdominal distension and did not pass flatus/ stools. X-ray showed air-fluid levels. Adhesive obstruction was suspected. She was managed conservatively and oral Upper GI contrast follow-through was done showing no contrast reaching large bowel till 48 hrs. Then the next day, she passed a lot of stools with flatus. She was started orally and discharged after 25 days of hospital stay.

Results: The child is healthy after 1-year of follow-up. She was started on medications for Trichotillomania and trichophagia after a psychiatric consultation. 

Discussion: Trichobezoars are usually encountered in young females with psychological disorders, where chronic malnutrition is often noticed. So, after surgery, refeeding syndrome should always be kept in mind before starting orally and it should be done as per NICE guidelines. Also, recurrences after surgery are rare but psychiatric consultation and regular follow-up after treatment, as done in our case, should be considered for all these cases. 

Keywords: Trichobezoar, Rapunzel Syndrome, Trichophagia, Refeed Syndrome, subacute intestinal obstruction