Case toothpick

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Toothpick injury mimicking renal colic: case report and systematic review

We describe a case of a patient with left flank pain that was caused by a perforation in the splenic flexure of the colon by a toothpick. We conducted a systematic review of the literature to examine the nature of injuries caused by ingested toothpicks. Articles were analyzed for the following outcome variables: presenting complaint, site of injury, recollection of toothpick ingestion, time to presentation, findings from imaging studies, and mortality. Most patients (70%) presented with abdominal pain. Few patients (12%) remember swallowing a toothpick. The onset of symptoms ranged from <1 day to 15 years. Toothpicks caused perforation most frequently at the duodenum and the sigmoid. In some cases, toothpicks migrated outside the gastrointestinal tract and were found in the pleura, pericardium, ureter, or bladder. Toothpicks were apparent on imaging studies in 14% of the cases. The definitive diagnosis was most commonly made at laparotomy (53%), followed by endoscopy (19%). Overall mortality was 18%. Ingested toothpicks may cause significant gastrointestinal injuries, and must be treated with caution.

Sours: https://pubmed.ncbi.nlm.nih.gov/12217469/
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Toothpick ingestion complicated by cecal perforation: case report and literature review

World Journal of Emergency Surgeryvolume 9, Article number: 63 (2014) Cite this article

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Abstract

Background

Diverticulitis and carcinoma represent the most common causes of colon perforation, but other causes, like ingestion of foreign bodies, should be taken into account.

Case presentation

We report the case of a 64-year old man presenting in our Emergency Department with a 2 days history of right lower abdominal pain, nausea, vomiting and low grade fever. Physical examination evocated mild pain with positive rebound tenderness in the right lower abdominal quadrant, and positive right costovertebral angle tenderness. Routine blood tests, abdominal X-rays and CT scan were inconclusive for perforation. At explorative laparoscopy a cecal perforation with localized peritonitis was found, and a right colectomy was performed due to the suspicion of cancer. Histological examination confirmed the presence of a perforation caused by a piece of wood (toothpick) of 6 cm in length.

Conclusions

Foreign body ingestion should be taken into account in the evaluation of acute abdominal pain. A detailed patient’s history may be crucial for a correct diagnosis and treatment.

Background

Diverticulitis and carcinoma represent the most common causes of colon perforation. Other causes are iatrogenic perforation, penetrating abdominal trauma, and ingestion of foreign bodies. When animal bones, needles, toothpicks or other sharp pointed objects are ingested, the risk of perforation is even higher[1].

Toothpick ingestion is a relatively rare event that may results in serious gut injuries with peritonitis, sepsis or even death. Interestingly, a 4-year survey performed in the United States found 8176 reported toothpick-related injuries yearly, a rate of 3.6 per 100000 person-years[2]. We report a case of an unintentional ingestion of a toothpick causing cecal perforation.

Case presentation

A 64-year-old man was referred to our emergency department with a two days history of right lower abdominal pain, nausea, vomiting and low grade fever. His vital signs were normal, except for a central body temperature of 38°C. There was no history of previous abdominal surgery. Physical examination evocated mild pain with positive rebound tenderness in the right lower abdominal quadrant, and positive right costovertebral angle tenderness. There was no evidence of intra-abdominal masses.

Routine blood tests were normal except for a WBC count of 11,860/mm3 with 84,6% neutrophils. On plain abdominal X-rays the small bowel was distended and dislocated on the left upper abdominal quadrant with some air-fluid levels (Figure 1a). A contrast-enhanced abdominal computed tomography (CT) scan confirmed bowel occlusion with extreme ileum distension and about 50 ml of free fluid in the Douglas pouch; no evidence of pneumoperitoneum (Figure 1b). However, the cause of this obstruction remained unclear. The patient underwent explorative laparoscopy. A localized peritonitis around the cecum was found. The procedure was converted to a median laparotomy. A right colectomy with side-to-side semimechanical ileo-colic anastomosis was performed due to the suspicion of cancer. The patient made an uneventful recovery and was discharged on postoperative day 7th. The histological examination confirmed the presence of a transmural cecal perforation with abscess caused by a piece of wood (toothpick) of 6 cm in length (Figure 2). The patient admitted of having ate meat rolls as main course for dinner three days before hospital admission.

a) X-ray of the abdomen (sagittal plane) showing distension of the small bowel with air fluid levels and no free air. b) Contrast enhanced computed tomography (CT) slide (coronal plane). Extreme distension of the colon. No evidence of free air in the peritoneal cavity.

Full size image

Operative specimen showing the toothpick (arrows) and the site of transmural cecal perforation.

Full size image

Literature review

A recent Medline literature research identified 136 case reports of ingested toothpicks[3]. Male gender, toothpick chewing habit, meals containing toothpicks and accompanied by alcoholic drinks were the main risk factors associated with toothpick ingestion. Most of the toothpicks were swallowed during meal time. Perforation of the alimentary tract occurred in 80% of these patients (Table 1); in one-third of them the toothpick had migrated into adjacent organs (liver, retroperitoneum, inferior vena cava, etc.). Figure 3 depicts the typical sites of toothpick lodgement along the alimentary canal. In 37% of the patients the toothpick had reached the colon[3]. Although the definitive identification of a toothpick on preoperative imaging is rare, a toothpick perforating the cecum after unconscious ingestion has been detected by ultrasound and CT scan in one patient[4].

Full size table

Localization of toothpicks along the alimentary tract after ingestion. Perforation occurred in 80% of the patients (from reference[3]).

Full size image

Discussion

Toothpick ingestion is a medical emergency since it leads to acute abdomen and gut perforation. In fact, most patients swallow toothpicks while eating sandwiches and are not able to recall or even unaware of this event. Since spontaneous elimination of these sharp foreign bodies through the gastrointestinal tract is unlikely, foreign body ingestion should be taken into account during the evaluation of acute abdominal pain.

The correct diagnosis is very difficult because of the low sensitivity of diagnostic investigations (Table 1). Endoscopy can be very helpful when the toothpick is localized in the upper-GI tract[5]. The CT scan may be able to identify the site of perforation and the extent of intra-abdominal inflammation either with or without abscess formation. Although the diagnostic yield is quite low, upper gastrointestinal endoscopy and ultrasound examination may be recommended in asymptomatic patients who are aware of the toothpick ingestion and seek medical advice within 24–48 hours[3].

Unfortunately, our patient was unaware of swallowing a wood toothpick that rapidly progressed and reached the colon. CT scan was unable to identify the cause of symptoms. Considering the presence of an acute abdomen, with evidence of peritonitis, the patient was scheduled for surgical exploration and required hemicolectomy.

This case suggests that a potential cause of lethal hazard may be unknown to the patient, but most of all it emphasizes the difficulty of a correct diagnosis with the most widely used instrumental exams, as endoscopy, ultrasound or CT scan.

Consent

Consent to publish the case was obtained from our patient prior to discharge. The patient allowed us to share his story and clinical images because he understood the importance of raising awareness among physicians on this unusual surgical entity.

Abbreviations

Computerized tomography.

References

  1. 1.

    Ginsberg GG: Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc. 1995, 41: 33-38. 10.1016/S0016-5107(95)70273-3.

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    Budnick LD: Tooth-pick-related injuries in the United States, 1979 through 1982. JAMA. 1984, 252: 796-797. 10.1001/jama.1984.03350060040026.

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    Steinbach C, Stockmann M, Jara M, Bednarsch J, Lock JF: Accidentally ingested toothpicks causing severe gastrointestinal injury: a practical guideline for diagnosis and therapy based on 136 case reports. World J Surg. 2014, 38: 371-377. 10.1007/s00268-013-2307-z.

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    Zouros E, Oikonomou D, Theoharis G, Bantias C, Papadimitropoulos K: Perforation of the cecum by a toothpick:report of a case and review of the literature. J Emerg Med. 2014, 4: 133-137.

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    Ivatury RR, Moore FA, Biffl W, Leppeniemi A, Ansaloni L, Catena F, Peitzman A, Moore EE: Oesophageal injuries: Position paper, WSES, 2013. World J Emerg Surg. 2014, 9 (1): 9-10.1186/1749-7922-9-9. doi: 10.1186/1749-7922-9-9

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Author information

Affiliations

  1. Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, San Donato Milanese, Milano, Italy

    Andrea Lovece, Emanuele Asti, Andrea Sironi & Luigi Bonavina

  2. Department of Surgery, IRCCS Policlinico San Donato, 20097 San Donato Milanese, Milano, Italy

    Emanuele Asti

Corresponding author

Correspondence to Emanuele Asti.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

EA and AL were the surgeons who first met, examined and treated the patient. AL, EA and AS were responsible for writing the first draft of the manuscript. LB supervised the writing of the paper and completed the final editing. All the authors read and approved the final manuscript.

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Lovece, A., Asti, E., Sironi, A. et al. Toothpick ingestion complicated by cecal perforation: case report and literature review. World J Emerg Surg9, 63 (2014). https://doi.org/10.1186/1749-7922-9-63

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Keywords

  • Toothpick
  • Ingestion
  • Perforation
  • Peritonitis
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Item #091 - (310096 CV)

YELLOW SYNTHETIC SMALL TEXAS TOOTHPICK CV

Blades: LONG CLIP

Length Closed: 3

MFG List: $61.90

Our Price: $42.99

Item #12002 - (810096 SS)

ABALONE SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

MFG List: $191.80

Our Price: $129.99

Item #28703 - (610096 SS)

CHESTNUT SMOOTH BONE SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

MFG List: $77.50

Our Price: $52.99

Item #60180 - (610096 SS)

SPARXX WHITE JIGGED SYNTHETIC SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

MFG List: $63.00

Our Price: $42.99

Item #8854 - (610096 SS)

NATURAL SMOOTH BONE SMALL TX TOOTHPICK W/FAITH ON HANDLE

Blades: LONG CLIP

Length Closed: 3

Our Price: $60.99

Item #11202 - (1010096 SS)

PATRIOT KIRINITE SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

MFG List: $86.30

Our Price: $58.99

Item #8469 - (R510096 SS)

RED STAG SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

MFG List: $123.30

Our Price: $84.99

Item #22419 - (210096 SS)

BLACK SYNTHETIC SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

Special Price: $33.99

Item #22470 - (410096 SS)

SMOOTH PURPLE SYNTHETIC SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

Special Price: $35.99

Item #501612 - (910096 SS)

PUMPKIN BOX SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

Our Price: $58.98

Limited Availability

Item #105734 - (EX10096 SS)

SN TOOTHPICK MAMMOTH TOOTH PRISM YELLOWHORSE CUSTOM

Blades: LONG CLIP

Length Closed: 3

Our Price: $349.98

Limited Availability

Item #22531 - (410096 SS)

SMALL TEXAS TOOTHPICK BURGUNDY SYNTHETIC

Blades: LONG CLIP

Length Closed: 3

Special Price: $36.99

Item #601612 - (910096 SS)

SMALL TEXAS TOOTHPICK CLASSIC CASE LOGO

Blades: LONG CLIP

Length Closed: 3

Our Price: $58.98

Limited Availability

Item #23437 - (1010096 SS)

SMALL TEXAS TOOTHPICK SPARXX BLUE PEARL KIRINITE

Blades: LONG CLIP

Length Closed: 3

MFG List: $87.20

Our Price: $59.99

Quantity Produced: 100

Item #105774 - (EX10096 SS)

SN SMALL TX TOOTHPICK MOP/APACHE BOULDER YELLOWHORSE CUSTOM

Blades: LONG CLIP

Length Closed: 3

Our Price: $249.99

Limited Availability

Item #22764 - (610096 SS)

SMALL TEXAS TOOTHPICK GREEN KENTUCKY BLUEGRASS BONE

Blades: LONG CLIP

Length Closed: 3

Special Price: $41.99

Item #22864 - (610096 SS)

SMALL TEXAS TOOTHPICK JIGGED BLACK SYNTHETIC

Blades: LONG CLIP

Length Closed: 3

Special Price: $32.99

Item #81095 - (310096 SS)

YELLOW SYNTHETIC SS - SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

MFG List: $61.90

Our Price: $42.99

Item #50494 - (EX10096 SS)

SMALL TEXAS TOOTHPICK NATURAL GIRAFFE BONE

Blades: LONG CLIP

Length Closed: 3

MFG List: $158.90

Our Price: $108.99

Item #22832 - (610096 SS)

ANTIQUE BONE SMALL TEXAS TOOTHPICK W/JOB BOLSTER

Blades: LONG CLIP

Length Closed: 3

Our Price: $50.99

Limited Availability

Item #52837 - (610096 SS)

SMALL TEXAS TOOTHPICK - ANTIQUE BONE ROGERS CORN COB JIG

Blades: LONG CLIP

Length Closed: 3

MFG List: $75.20

Our Price: $49.99

Quantity Produced: 100

Item #105794 - (EX10096 SS)

SM TOOTHPICK TRI-MAMMOTH TOOTH-TUSK -TIBIA - YELLOWHORSE

Blades: LONG CLIP

Length Closed: 3

Our Price: $249.99

Item #23617 - (410096 SS)

SMALL TEXAS TOOTHPICK - NAVY BLUE SYNTHETIC

Blades: LONG CLIP

Length Closed: 3

MFG List: $56.80

Our Price: $38.99

Quantity Produced: 250

Item #9015 - (810096 SS)

MOTHER-OF-PEARL SMALL TEXAS TOOTHPICK - CASE SELECT

Blades: LONG CLIP

Length Closed: 3

Our Price: $164.99

Item #22518 - (610096 SS)

GRAY JIGGED BONE SMALL TEXAS TOOTHPICK

Blades: LONG CLIP

Length Closed: 3

Our Price: $49.99

Item #52804 - (610096 SS)

SMALL TEXAS TOOTHPICK - MEDITERRANEAN BLUE BONE

Blades: LONG CLIP

Length Closed: 3

MFG List: $72.90

Our Price: $49.99

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Case Tiny Traditionals: Not a Lot of Knife, Yet... a Lot of Knife

Someone will be very lucky with you. I was very pleased. I unexpectedly admitted to myself that I began to fall in love with my friend's brother. There was romance in the air, I was already a little drunk.

Similar news:

And she did it, which she was still happy about. Paola kept her black panties, which were wet through when Paola just massaged Clara's beautiful shoulders. She sometimes wore them herself at home, and remembered how Clara held her penis and pressed it to her lips. Since her penis was too big for these panties, only her balls and the base of the penis were placed there.

Paola liked the way the boss's panties squeezed and teased her genitals slightly.



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