Raul Mederos, MD
Chief Surgical Resident
Payman Danielpour, MD
Chief Surgical Resident
Medical Student III
Donald Minervini, MD
Department of Surgery
Mount Sinai Medical
Miami Beach, FL
Perforation of the bowel by an ingested foreign body can be easily diagnosed if the patient recalls the ingestion. Often this is not the case, and the diagnosis is made intraoperatively. The exception is when the foreign body is radiopaque and can be detected on radiologic studies. The authors report the case of a patient who underwent an exploratory laparoscopy once an acute abdomen was evident, and a toothpick perforation of the small intestine was found. In the November 2006 issue of Surgical Rounds, we reviewed a case of fishbone perforation. If the foreign body is irregular, like a fishbone, resection of the bowel is necessary. In contrast, a smooth foreign body, like a toothpick, occasionally can be extracted. In the presented case report, the authors resected back to the healthy bowel because considerable reaction was observed around the perforation site. Exteriorizing the damaged segment of bowel and performing the resection and anastomosis extracorporeally seems a good choice of treatment.
Thomas Gadacz, MD
Series Guest Editor
Department of Surgery
Medical College of Georgia
Ingested toothpicks can cause considerable injury to the gastrointestinal (GI) tract because they are often pointed at each end. Swallowed toothpicks are fairly common and account for approximately 9% of all intestinal perforations by foreign objects.1 Many patients with toothpicks lodged in the GI tract have no recollection of the ingestion.1-5 We report a case of toothpick ingestion that went unrecognized by the patient and discuss how injuries from such events can mimic many pathologic entities, including Crohn's ileitis.
The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.
A 35-year-old man presented to the emergency department with a 3-day history of unrelieved abdominal pain, one episode of bloody emesis, and a low-grade fever of 100°F. The pain was initially localized to the periumbilical region but later became diffuse throughout all four quadrants and intensified with minimal movement. The patient reported no chills or diarrhea. He had no history of peptic ulcer disease or any other significant medical history, did not use tobacco, and was not taking any medication.
Physical examination revealed a temperature of 98.7°F, blood pressure of 146/90 mm Hg, and a pulse of 114 beats per minute. His bowel sounds were hypoactive on auscultation. There was moderate abdominal distention, and diffuse tenderness with minimal rebound and guarding was elicited in all quadrants on palpation. Significant laboratory findings included a white blood cell (WBC) count of 15.4 x 109/L (normal, 4.5—11 x 109/L) with a left shift and a hemoglobin count of 15.8 g/dL (normal, 14.0—17.5 g/dL). The patient's electrolyte panel and liver and pancreatic enzymes were normal. His stool was hemoccult negative. Abdominal and pelvic computed tomography (CT) scans revealed a normal appendix; a long segment of terminal ileum with significant thickening, fat stranding, and dilatation; and no free intraperitoneal fluid or air (Figure 1). The patient was admitted to the hospital with a working diagnosis of Crohn's disease.
|Figure 1—Abdominal and pelvic CT scan showing a long segment of terminal ileum with significant thickening, fat stranding, and dilatation. The toothpick is not visible.|
|Figure 2—Intraoperative images (A and B) showing a toothpick perforating the distal ileum.|
On hospital day 1, the patient's abdomen became increasingly distended. He experienced generalized abdominal tenderness, predominantly in the right lower quadrant, which persisted despite bowel rest and nasogastric decompression. His temperature was 98.4°F, and his WBC count was elevated (16.1 x 109/L). He had not been treated with antibiotics.
On hospital day 2, the patient developed an acute abdomen with peritoneal signs despite conservative management. An exploratory laparoscopy was undertaken, which confirmed a normal appendix, identified multiple small bowel adhesions, and revealed a wooden toothpick protruding through the bowel wall approximately 20 cm from the ileocecal valve (Figure 2). The toothpick had not been visualized on CT scanning. Approximately 10 cm of affected ileum was resected laparoscopically. The remainder of the bowel was investigated, and the abdominal cavity was thoroughly irrigated.
The patient had an uneventful postoperative recovery and was discharged from the hospital on postoperative day 6. When questioned about the toothpick, he stated that he had quickly eaten a sandwich embedded with numerous toothpicks 3 days before his admission, but he did not recall swallowing any of them. He also admitted to consuming several beers at that time and may have been inebriated.
The types of foreign objects ingested are as varied as the patients who ingest them, and there is often no recollection of the event.1 Several predisposing factors to the incidental swallowing of foreign bodies have been reported, including carelessness, intoxication, rapid bolting of food, decreased sensitivity of the palatal surface (full upper dentures), and a habit of chewing on foreign objects.2 In our patient's case, it was the rapid bolting of food and, possibly, alcohol consumption that caused him to unknowingly ingest a toothpick.
Several areas in the GI tract are prone to impaction of ingested foreign bodies, including the upper and lower esophageal sphincters, pylorus, duodenum, ileocecal valve, and anal area. Sites of perforation usually include the ileum, appendix, or colon.1 The terminal ileum is one of the more common sites for obstruction and perforation, especially when a foreign body with two sharp, pointed ends is involved, such as a toothpick.1 Henderson and Gaston reported the small bowel as the most common site for perforation followed by the cecum.3 Our patient's injury occurred at the terminal ileum and correlates with Henderson and Gaston's findings.
Due to the variety of presentations of bowel injuries, those induced by toothpick ingestion can mimic other diseases. For instance, imaging studies have shown that the accidental ingestion of toothpicks induces changes consistent with appendicitis, ileitis, and lymphoma of the small bowel.4 This correlates with the CT findings observed in our patient, who was thought to have Crohn's ileitis based on what was observed. One third of individuals known to have ingested toothpicks experienced complications, including small and large bowel perforations, fistula formation, obstruction, sepsis, and death.1-8
Our case report highlights some important points regarding the presentation and diagnosis of small bowel perforation secondary to toothpick ingestion. First, physical findings of right lower quadrant pain, rebound tenderness, and guarding on palpation correspond to the location of the toothpick perforation in the distal small bowel. Second, prompt surgical intervention can aid in the diagnosis, treatment, and prevention of major complications from toothpick ingestion. Last, radiographic studies are by no means entirely reliable in diagnosing perforations from a toothpick, because wooden toothpicks are not radiopaque.