Accidentally Ingested Toothpicks Causing Severe Gastrointestinal Injury: A Practical Guideline for Diagnosis and Therapy Based on 136 Case Reports

An unusual cause of abdominal pain in an older female

Toothpick ingestion is an uncommon condition. It has been reported that an estimated incidence of 3.6 toothpick related injuries per 100,000 people per year. However, the incidence of toothpick-related gastrointestinal tract perforation is as high as 80%, with small bowel perforation accounting for 18% of cases. Common symptoms associated with toothpick ingestion include abdominal pain, fever, nausea, diarrhea, and constipation. However, it may lead to peritonitis, abscesses, and sepsis in severe cases. The diagnosis of toothpick ingestion is difficult. Only a minority (12%) of patients remember eating toothpicks and the sensitivity of computed tomography (CT) and endoscopy is 43% and 70%, respectively. When a toothpick penetrates the small intestine or is accompanied by other adverse events such as peritonitis, the vast majority of patients undergo surgery. Double-balloon enteroscopy (DBE) is not only an examination method for small intestinal diseases, but also an endoscopic treatment for the removal of sharp foreign bodies such as toothpicks. We report an elderly woman who was diagnosed as toothpick penetrated the jejunal wall and successfully retrieval under DBE. To our best knowledge, there is currently only one report of removing toothpick from the small intestine using DBE. We figured that DBE is a feasible, safe, and effective treatment when toothpicks penetrate the small intestinal wall without other adverse events based on our presentation.

Endoscopic management of ingested toothpick resulting in duodeno-ureteric fistula

Toothpicks are commonly used but rarely ingested. Unlike most foreign bodies, if accidentally swallowed these rarely spontaneously pass. The duodenum has been reported as the most common site of toothpick foreign body lodgement in the upper gastrointestinal tract. We report the case of a 57-year-old presenting with recurrent urosepsis after non recognition of a toothpick impaction in the duodenum with fistulisation into the right renal pelvis. Endoscopic removal of the foreign body was successful in management of the urosepsis.

Endoscopic Removal and Conservative Treatment of a Small Bowel Perforation Caused by a Toothpick: A Case Report

This case report describes a unique instance of small bowel perforation in a 49-year-old woman caused by an ingested toothpick. Initially suspected of colonic diverticulitis, a final diagnosis of small bowel perforation was made later, and the toothpick was successfully removed via endoscopy. This case emphasizes the need to consider foreign body ingestion in the differential diagnosis of abdominal pain and demonstrates the feasibility of conservative endoscopic approaches in similar cases.

Case report and literature review: Orally ingested toothpick perforating the lower rectum

Introduction

Most foreign bodies (FBs) can spontaneously pass through the gastrointestinal tract. Sharp FBs are believed to be able to puncture any part of the gastrointestinal tract, causing perforation and potentially secondary damage to adjacent organs.

Case description

A 44-year-old man complained of having persistent dull pain in the perianal region. He was diagnosed with a toothpick impacted into the wall of the lower rectum after accepting a digital rectal examination of the lower rectum and a pelvic computed tomography (CT). The surgeon extracted the FB using vascular forceps guided by the operator's index finger. The patient was discharged after intravenous ceftriaxone was given for 6 days. A follow-up pelvic CT performed 2 weeks after surgery revealed that the perirectal fat and muscles had already normalized.

Conclusion

A systematic review of relevant literature from the past decade was performed to summarize the imaging features of an orally ingested toothpick perforating the gastrointestinal tract. The location of abdominal pain is an important clue for the diagnosis of toothpick perforation, and a CT examination is recommended as the first option for the detection of an ingested toothpick. Determining the location of the toothpick perforation and assessing the severity of local inflammation are important bases for the selection of treatment.

Anorectal ulcer caused by an ingested toothpick

We present a case report of an anorectal ulcer cause by an accidentally ingested toothpick, with radiologic an endoscopic images. This is a rare cause of foreign bodies in digestive tract, though it has a high rate of complications.

A Right-Angled Thorn in the Bowel: A Curious Case of Small Bowel Perforation

We present a 45-year-old man with small bowel perforation resulting from the inadvertent ingestion of a right-angled thorn of the Gum Arabic plant (Vachellia nilotica). The diagnosis was made, and an emergency laparotomy was performed for suspected enteric peritonitis. The thorn was found projecting from the terminal ileum with a minimal intra-peritoneal fluid collection. The thorn was removed, and the perforation site was repaired primarily with absorbable sutures. The lack of a reliable history of foreign body ingestion makes it impossible to arrive at an accurate preoperative diagnosis in patients presenting with perforation peritonitis. Radiological investigations have a low sensitivity for detecting radiolucent vegetative foreign bodies as the cause of bowel perforations. Primary repair should be preferred over resection procedures in the management of foreign body-induced small bowel perforations.

Case report: An unusual case of small bowel bleeding and common iliac artery pseudoaneurysm caused by an unnoticed swallowed toothpick

Gastrointestinal (GI) bleeding is a common clinical condition that can be caused by a variety of reasons. Bleeding can occur anywhere in the GI tract, and it usually presents as vomiting of blood, melena or black stools. We herein present a case of a 48-year-old man who was ultimately diagnosed with perforation of the lower ileum, pseudoaneurysm of the right common iliac artery, lower ileum-right common iliac artery fistula, and pelvic abscess caused by accidental ingestion of a toothpick. This case suggests that accidental ingestion of a toothpick may also be the cause of GI bleeding in some patients. For patients with unexplained GI bleeding, especially those with small bowel bleeding, a rational and combined use of gastroduodenoscopy, colonoscopy, unenhanced and contrast-enhanced abdominal CT can help detect the causes of GI bleeding and improve diagnostic accuracy.

Accidentally ingested wooden toothpick, perforation of a sigmoid diverticulum and mimicking acute colonic diverticulitis: A case report and literature review

INTRODUCTION AND IMPORTANCE

Ingested wooden toothpick (WT) represents a rare cause of acute abdomen. Preoperative diagnosis of ingested WT is a challenge because of its unspecific clinical presentation, the low sensitivity rate of radiological investigations and the patient's inability to often recall the event of swallowing a WT. Surgery represents the main treatment in case of ingested WT-induced complications.

CASE PRESENTATION

A 72-year-old Caucasian male presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting and fever. Physical examination revealed LLQ abdominal pain and rebound tenderness with muscle guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography (CECT) showed colonic diverticulosis, wall thickening of the sigmoid colon, pericolic abscess, regional fatty infiltration, a suspicion of sigmoid perforation secondary to a foreign body. The patient underwent diagnostic laparoscopy: a sigmoid diverticular perforation caused by an ingested WT was noticed and a laparoscopic sigmoidectomy with end-to-end Knight-Griffen colorectal anastomosis, partial omentectomy and protective loop ileostomy were performed. The postoperative course was uneventful.

CLINICAL DISCUSSION

The ingestion of a WT represents a rare but potentially fatal condition which may cause GI perforation with peritonitis, abscesses and other rare complications if it migrates out of the GI tract.

CONCLUSION

Ingested WT may cause serious GI injuries with peritonitis, sepsis or death. Early diagnosis and treatment are crucial for reducing morbidity and mortality. Surgery is mandatory in case of ingested WT-induced GI perforation and peritonitis.

Bacteremia Associated With a Toothpick Lodged in the Duodenal Wall

Toothpick ingestion and perforation of the gastrointestinal tract, although a very rare phenomenon, carries a very high mortality risk. Most cases of toothpick ingestion remain unnoticed until very late. The symptoms are often vague, with the most common being abdominal pain. Any obscure case of abdominal pain with bacteremia must be investigated for foreign body ingestion and perforation. A CT scan is the best initial diagnostic modality for toothpick perforation but has low sensitivity with laparoscopy, and endoscopy is the preferred diagnostic tool. No single bacterium is involved in bacteremia due to toothpick ingestion. Surgical or endoscopic removal of the impacted toothpick along with prompt antibiotic therapy leads to excellent outcomes. If left untreated or in case of a late diagnosis, it may lead to life-threatening consequences. Here, we present a case of a 44-year-old man who had ingested a toothpick that pierced through and was lodged in the duodenal wall, leading to bacteremia. The patient was successfully treated and discharged.

Pain in the Gut: An Intriguing Case of Toothpick Ingestion Causing Gastric Perforation

Toothpick ingestion is a medical emergency requiring urgent intervention. Swallowed toothpicks can cause intestinal perforation, bleeding, or damage to the surrounding organs. Herein, we describe a unique case of a geriatric patient with a history of peptic ulcer disease who presented to the emergency department for the evaluation of abdominal pain and nausea. Gastric wall thickening concerning for a gastric neoplasm was observed on a computed tomography (CT) scan of the abdomen and pelvis. An esophagogastroduodenoscopy (EGD) revealed an embedded toothpick with a contained gastric perforation, and the foreign body was retrieved with a grasper device. Given the rare presentation, nonspecific symptoms, inability to recall, and often inconclusive imaging, a high index of suspicion is needed for early diagnosis and treatment of toothpick ingestion.

Sepsis due to kidney injury caused by a toothpick: a case report and literature review

BACKGROUND

Toothpicks are common foreign bodies which may injure surrounding organs leading to a series of atypical symptoms. We present a rare clinical case that septicemia caused by a toothpick penetrated into the right kidney.

CASE PRESENTATION

We describe a 51-year-old patient who presented with right-sided backache and hematuresis for 2 days. Blood culture persistently grew Streptococcus gordonii. Ultrasound of the patient's urinary tract revealed a strong striated echo in the middle of the right kidney. Complete abdominal computed tomography revealed a duodenal foreign body penetrating into the right kidney. The toothpick was removed under endoscopy and hemostasis was given. Antibiotic treatment was upgraded. The patient was recovered and discharged from his stay on the fifteenth day.

CONCLUSIONS

Early identification of the etiology of sepsis can effectively alleviate patient's distress and reduce hospital stay. Clinicians should identify the source of sepsis through a medical history and examination.

Evaluation of the risk factors for severe complications and surgery of intestinal foreign bodies in adults: a single-center experience with 180 cases

BACKGROUND

Foreign bodies (FBs) lodged in the intestine or causing intestinal complications are uncommon in clinical practice but may pose diagnostic difficulties and prove life-threatening. This study aimed to evaluate the risk factors for severe complications and surgery to aid clinicians in the diagnosis and management of intestinal FBs.

METHODS

We performed a retrospective analysis of patients in whom FBs were lodged in the intestine or caused complications from 2010 to 2020 in the First Affiliated Hospital of Wenzhou Medical University (Zhejiang, China). The characteristics of the patients and FBs, symptoms, imaging findings, diagnostics, treatment strategies, and clinical outcomes were analysed. Furthermore, the risk factors for complications and surgery were investigated.

RESULTS

In total, 180 patients were included in our study. Most patients (76.1%) were unable to provide a history of ingestion. Bezoars were the most common FBs (35.6%). The FBs were mainly located in the duodenum (32.8%) and the ileum (27.8%). Surgical removal of FBs was successful in 89 (49.4%) patients and endoscopic removal in 54 (30.0%) patients. Eleven with perforations were treated conservatively. FBs located in the jejunum or ileum were more likely to cause severe complications than those located in the duodenum. FBs located in the jejunum, ileum, or sigmoid colon were more likely to undergo surgery, and severe complications were an independent risk factor for surgery.

CONCLUSION

Intestinal FBs, often localized in angulation, are likely to be misdiagnosed because most patients do not provide a history of FB ingestion. Surgery and endoscopic therapy are the most commonly used treatment modalities. Surgery is not mandatory in clinically stable patients with small and contained perforations. FBs located in the jejunum or ileum are risk factors for both complications and surgery.

Endoscopic Removal of Sharp-Pointed Foreign Bodies with Both Sides Embedded into the Duodenal Wall in Adults: A Retrospective Cohort Study

Purpose

Sharp-pointed FBs with both sides embedded in the duodenal wall are rare. Compared with smooth edged FBs, sharp objects are more likely to be associated with significant adverse events, when penetrating the wall of the digestive tract. The clinical features of patients who experienced sharp-pointed FBs embedded in both sides of the duodenum were retrospectively analyzed, as were the efficacy and safety of endoscopic removal of these FBs.

Patients and Methods

This retrospective study included 21 adults with both sides of sharp-pointed FBs embedded into the duodenal wall who were admitted to the Second Xiangya Hospital in China between January 1, 1996, and May 31, 2021. Data associated with the endoscopic removal of these FBs were collected from the electronic medical record system (EMRS) of the hospital.

Results

The incidence rate of duodenal total FBs and FBs embedded in both sides was 8.87% and 1.03%, respectively. The success rate of endoscopic treatment was 100.00% in 124 patients without embedded duodenal FBs and 97.14% in 35 patients with one side embedded duodenal FBs. Of the 21 patients with FBs embedded in both sides of the duodenal wall, endoscopic removal was successful in 85.71% of patients, whereas 14.29% required surgery. FBs removed from these patients included toothpicks in 12; needles in 3; jujube pits in 2; and a chopstick, dentures, fish bones, and chicken bones in one each. Most of these 21 FBs were located in the bulb and descending duodenum, followed by the third part of duodenum.

Conclusion

Sharp-edged FBs with both sides embedded in the duodenal wall are rare. Endoscopic removal may be considered as a feasible, safe, and effective method of removing sharp-pointed FBs with both sides embedded in the duodenal wall. And if endoscopic removal is unsuccessful, surgical management can be a secondary option.

Use of Mini-Percutaneous Nephrolithotomy Technique to Remove Extra-Peritoneal Foreign Bodies

Case series

Patients: Male, 31-year-old • Male, 70-year-old

Final Diagnosis: Extra-peritoneal foreign bodies

Symptoms: Abdominal pain and fever

Medication: —

Clinical Procedure: Mini-percutaneous nephrolithotomy

Specialty: Radiology

Sacral plexus disorder caused by a wooden toothpick in the rectum

A 67-year-old man presented with a 2-month history of pain in his right buttock and lower limb. MRI depicted right L5/S1 lateral recess stenosis requiring surgical treatment; however, preoperative CT showed an approximately 7 cm long, thin, rod-shaped structure in the rectum, which was ultimately determined to be an accidentally ingested toothpick. It was removed surgically 6 days after diagnosis, because right leg pain worsened rapidly. The pain disappeared thereafter, and the symptoms have not recurred since. The pain might have been localised to the right buttock and posterior thigh in the early stages because the fine tip of the toothpick was positioned to the right of the anterior ramus of the S2 spinal nerve. Although sacral plexus disorder caused by a rectal foreign body is extremely rare, physicians should be mindful to avoid misdiagnosis.

Necrotizing fasciitis from an iliopsoas muscle abscess caused by a toothpick: A case report and literature review

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Ingested toothpick caused gut injury are a rare event, but caused retroperitoneal infection are relatively rare.

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The diagnosis of psoas abscesses associated with toothpicks is challenging and should not be overlooked.

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Gastrointestinal symptoms are uncommon when the gut perforation site is over the retroperitoneal space.

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Appropriate early surgical intervention is recommended. Thorough debridement is essential if the origin of infection is unknown.

Introduction

Psoas muscle abscess is rare and can become more complicated to treat after they have progressed to necrotizing fasciitis. The data of secondary psoas muscle abscess cause by ingested toothpick are limited in the literature. We have done an extensive literature review and found a number of 8 cases (including our new case) of ingested toothpicks causing iliopsoas muscle abscess.

Presentation of case

We present a 70-year-old man with unremarkable medical history experienced left flank pain for several days with radiated to left thigh and unable to walk. He initially exhibited drowsiness at emergency department with fever and chillness. Computed tomography showed iliopsoas abscess and necrotizing fasciitis. This patient received emergent surgical debridement and a toothpick was found lodged in the deep portion of the left psoas muscle. He was tolerated to the treatment and discharged on 58 days after the operation.

Discussion

A review of the literature revealed only eight reported cases since 1946 (including ours) of ingested toothpicks migrating into the iliopsoas muscle and causing abscess formation or necrotizing fasciitis. Three of the cases did not exhibit gut perforation, possibly because of self-healing of the wound. Gastrointestinal symptoms are not always apparent when the perforation site is over the retroperitoneal space. Thorough debridement is essential if the origin of infection is unknown.

Conclusion

Ingestion of a foreign body may be asymptomatic, the present case and a review of the literature indicated that ingested toothpicks can cause severe morbidity or even mortality. The diagnosis of psoas abscesses associated with toothpicks is difficult, and such cases should not be overlooked. Appropriate early surgical intervention is recommended.

Successful Endoscopic Removal of Toothpick Perforating Gastric Antrum With Over-the-Scope Padlock Clip Closure

Our unique case demonstrates the use of an over-the-scope Padlock clip for closure of a sharp foreign body induced gastric perforation, avoiding the need for surgical intervention. A 47-year old female presented with a two-day history of abdominal pain with nausea. Abdominal CT scan revealed a linear density in the distal body of the stomach extending outside the lumen. Endoscopic evaluation revealed a toothpick perforating through the wall of the gastric antrum. Endoscopic removal was performed, and closure of the full-thickness defect was achieved with an over-the-scope Padlock clip. The patient subsequently made an uneventful recovery, with no reported complications at two-year follow-up. Early endoscopic removal and closure of gastric luminal perforations by over-the-scope Padlock clips are viable alternative treatments for defects previously considered only amenable to surgical repair. Endoscopic treatment of gastrointestinal perforations has shown to decrease the morbidity and mortality associated with more invasive surgical procedures.

Laparoscopic treatment of right colic flexure perforation by an ingested wooden toothpick

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Ingested wooden toothpick.

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Laparoscopic suture.

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Sharp foreign bodies.

Introduction

Ingestion of a toothpick, both accidentally and intentionally, is a rare event.

Presentation of case

We present the case of a 42-years old man who was admitted to the emergency department at our Institution presenting with a 5-days history of right sided abdominal pain. Laboratory blood count reported leukocytosis and alteration of principal inflammation index; at the abdominal ultrasound no signs of perforation or collection were described.

Discussion

Indication to surgery was posed and an explorative laparoscopy was performed. The presence of local peritonitis at the right colonic flexure secondary to a full thickness bowel perforation caused by a toothpick was found. There was also an acute phlegmonous appendicitis. A laparoscopic appendectomy and a full-thickness double running suture of the perforation were performed.

Conclusion

Awareness about dangers of ingested toothpicks needs to be taken and the intestinal track/trace of the toothpick is mandatory until its expulsion.

Toothpick-a rare cause of bowel perforation: case report and literature review

Bowel perforation is an emergency condition. Common causes of bowel perforation include infection, infarction, radiation enteritis, Crohn's disease, and cancer. Ingested foreign body causing bowel perforation is rare. Wooden toothpick-related injuries are uncommon. We report a case of ileal perforation caused by ingested wooden toothpick preoperatively diagnosed by ultrasound and computed tomography.

Ingested toothpick retrieved through a lumbar approach: a case report

Background

Ingested toothpick may cause severe complications if there is no intervention timely. Toothpicks that required surgical intervention often retrieved through exploratory laparotomy or laparoscopic exploration surgery under general anesthesia, while, those through lumbar approach have been rarely reported. Herein, authors report a case of ingested toothpick which removed through the lumbar surgical approach under local anesthesia and the patient has gained a considerable recovery.

Case presentation

A 57-year-old man was admitted to our hospital with distending pain in the right flank for more than 20 days. He had a history of accidental toothpick ingestion. Abdominal computed tomography (CT) scan and Color Doppler Ultrasound of the superficial tissue (right flank pain area) consistently revealed a linear lesion -corresponding to the toothpick- was located at the right flank next to the body surface. Surgery via lumbar approach was then successfully performed to retrieve the toothpick under local anesthesia. The post-procedural course was uneventful, and the patient was discharged on the third day after surgery, no complications were noted at the 18-month follow-up.

Conclusion

When a foreign body that causes perforation of the digestive tract remains for a relative long time (non-acute stage) and the perforation is close to the body surface, a local anesthesia surgery through the corresponding body surface may be a considerable choice.

Gastrointestinal bleeding as a result of entero-iliac fistula due to intestinal foreign body

Ingested toothpicks are a relatively rare event, but they may cause serious gut injuries and can be listed among rare causes of perforation, peritonitis, sepsis or death. Unless the foreign bodies were intentionally swallowed, many patients who ingested them fail to remember the event and they do not refer it during the medical history collection; this makes diagnosis problematic. In this work, a case of perforation of the sigmoid colon is described, caused by a toothpick ingestion. The patient had to be surgically treated because of a complication: the formation of an entero-iliac fistula with subsequent development of a pseudoaneurysm of the right external iliac artery. Vascular perforation due to toothpick ingestion has rarely been reported. In similar cases, it could be difficult to establishing the correct diagnosis because of the low sensitivity and accuracy rates of diagnostic investigations. The ingestion of foreign bodies should be kept in mind as an important differential diagnosis in patients with acute abdomen or chronic abdominal pain of unknown origin.

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Ingested toothpicks are a relatively rare event.

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These can be listed among rare causes of perforation, peritonitis, sepsis or death.

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It could be difficult to establishing the correct diagnosis because of the low sensitivity of diagnostic investigations.

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Vascular perforation due to toothpick ingestion has rarely been reported.

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The ingestion of foreign bodies should be kept in mind as an important differential diagnosis.

Ingested Foreign Body Imaging Using Point-of-Care Ultrasonography: A Case Series

The ingestion of foreign bodies is a common problem in the pediatric population. Emergent treatment of ingested foreign bodies is dependent on the type of foreign body ingested, patient symptoms, timing of ingestion, and the location of the foreign body. Although X-ray and computed tomography are the imaging techniques used most often to assess for foreign bodies, ultrasonography, which lacks ionizing radiation, may also be useful. This case series describes 8 cases of gastrointestinal tract foreign bodies and the utility of point-of-care ultrasonography for their real-time evaluation.

Surgery for intra-abdominal abscess due to intestinal perforation caused by toothpick ingestion: Two case reports

RATIONALE

Failure to pass though the gastrointestinal tract can result in inflammatory response, reactive fibrosis, and intestinal perforation. Fish bones, chicken bones, and toothpicks are the most common types of foreign substances that produce intestinal perforation during ingestion.

PATIENT CONCERNS

Case 1: A 49-year-old female was hospitalized with abdominal pain and a fever. The fever lasted for 5 days before hospitalization. Case 2: A 72-year-old male was hospitalized with abdominal pain and fever. The fever lasted for 4 days before hospitalization.

DIAGNOSES

Case 1: An abdominal pelvic computed tomography (APCT) scan revealed a large inflammatory mass formation and linear high-density material within the inflammatory mass. The presence of foreign bodies, including acupuncture needles or intrauterine devices was ruled out. Case 2: An APCT scan revealed that there was a small abscess formation measuring about 2.5 cm abutting the abdominal wall and a parasitic infestation was ruled out.

INTERVENTIONS

Case 1: An exploratory laparotomy was performed. After removal of the abscess pocket, the sigmoid colon was found to be perforated, and there was a firm, sharp foreign body in the abscess pocket that measured about 5 cm and resembled a toothpick. Case 2: Laparoscopic exploration was then performed. When the abscess was removed from the abdominal wall using a harmony scalpel, a 4 cm foreign body that resembled a toothpick appeared in the abscess pocket.

OUTCOMES

The patients recovered well after surgery and were discharged.

LESSONS

Two of the above case reports describe the cases in which the presence of toothpicks was suspected clinically, resulting in the surgery of intra-abdominal abscess caused by intestinal perforations.

Unusual case of a fatal upper esophageal trauma caused by a toothpick

The authors report the case of the unexpected death of a fifty-year-old female found by her partner in the bathroom floor. External examination revealed some contusions dispersed by different corporal areas and an unusually placed green discoloration of the anterior cervical region. After neck dissection and opening the esophagus, a three and a half centimeter wooden toothpick fragment was found at the upper region, covered by a purulent substance associated with puncture wounds. Histopathological and microbiological studies revealed "acute bilateral cervical cellulitis" and Klebsiella Oxytoca, respectively. Further investigation revealed that during the five days prior to her death, the victim was observed twice in an emergency department with complains of throat discomfort after eating some bread with salami. X-Ray and a laryngoscopy were performed but did not reveal any significant findings. Due to the victim's medical history, she was evaluated by a psychiatrist that dismissed a non-somatic setting due to the type of complains and the elevation of blood inflammatory parameters. Rinopharyngitis was then assumed as the most likely diagnosis and was treated accordingly. The victim died the following day. This case reports an unusual fatal traumatic lesion to the upper esophagus that is a very important remainder, particularly for clinical practitioners, to maintain a high degree of suspicion, avoid diagnostic biases such as those related to psychiatric disorders and meticulously evaluate patients in order to deliver the most evidence-based diagnosis possible. To the best of the authors' knowledge there are no other cases described in the literature of a death caused by esophageal toothpick lesion.

Wooden toothpick partially embedded in the gastric antrum: a case report of an unusual finding in open access gastrointestinal endoscopy

Ingested toothpick is an unusual occurrence in clinical practice. This is a medical emergency and all effort should be made to localize the toothpick and appropriate intervention instituted. We report a case of accidentally ingested toothpick with successful endoscopic removal in a case of a 24year old male who presented for open access endoscopy with complaint of abdominal pain. During endoscopy a foreign body (sharp object) was seen partially embedded at the gastric antrum which was later identified as a wooden toothpick. Endoscopic removal was done using a Caesar grasping forceps (CGF-1-240). No complication was reported during and after the procedure. Ingested toothpick should be managed as an emergency in all cases and should be considered an important differential diagnosis in clients with complaint of abdominal pain especially in open access endoscopy.

Funding

None.

Intestinal Perforation Secondary to Pits of Jujube Ingestion: A Single-Center Experience with 18 Cases

BACKGROUND

Ingestion of jujube pits is a common clinical problem, which can be difficult to diagnose and life-threatening if accompanied with intestinal perforation and peritonitis. In this study, 18 cases of intestinal perforation caused by ingestion of jujube pits were reviewed and summarized to discuss the clinical characteristics, diagnosis and treatments.

METHODS

From 2012 to 2018, a total of 18 patients diagnosed as intestinal perforation due to ingested pits of jujube in our center were retrospectively reviewed and the manifestations, laboratory tests, imaging examinations and treatment strategies were summarized.

RESULTS

The patients comprised of 11 males and 7 females with an average age of 63.5 years. The main clinical manifestation was abdominal pain. Twelve patients (67%) presented to the emergency department with signs of localized peritonitis. CT imaging revealed positive findings in 17 (94%) patients. Conservative treatments were attempted in 3 patients, and the other 15 patients received emergency surgical exploration, where 7 patients had more than one perforation identified during surgery. Five patients were admitted in the surgical intensive care unit after surgery. The average length of stay of all 18 patients was 9.8 days (range 5-24 days).

CONCLUSION

Ingestion of jujube pits is a common clinical problem and potentially leads to intestinal perforation and peritonitis. CT imaging is the first imaging modality of choice. Patients with milder symptoms might be managed with cautious conservative treatment, and patients with more than one perforation can be identified during surgery.

Impacted wooden toothpick in the stomach

Foreign body ingestion should be considered when evaluating acute onset epigastric pain, even if patients have no recollection of foreign body ingestion and suspicious conditions or habits, especially in the regions where toothpicks are used on a daily basis.

Toothpick Colon Injury Mimicking Colonic Diverticulitis

Although toothpick ingestion is rare, it can lead to fatal complications in the gastrointestinal tract. Diagnosing toothpick ingestion is difficult because most patients do not recall swallowing one. We report 2 cases of toothpick-ingestion-induced colon injury, mimicking diverticulitis. The first patient was a 47-year-old male who had received conservative treatment under the impression of his having diverticulitis in the cecum. Ultrasonography revealed a linear foreign body in the right lower abdomen; a subsequent laparoscopic examination revealed inflammation around the cecum, but no evidence of bowel perforation. A thorough investigation revealed a toothpick embedded in the subcutaneous fat and muscle layer of the lower abdominal wall; we removed it. The second patient was a 56-year-old male who had received conservative treatment under the impression of his having diverticulitis in the sigmoid colon. An explorative laparotomy revealed a toothpick piercing the sigmoid colon; we performed an anterior resection. Both patients were discharged without postoperative complications.

Small bowel perforation by toothpick

Toothpick ingestion is a rare but potentially fatal condition which may cause bowel perforation and rare complications if it migrates out of the gastrointestinal tract. This case report describes a delayed presentation of toothpick-induced small bowel injury leading to abdominal wall abscess and spondylodiscitis. A 51-year-old man was admitted twice with fever and loin pain, but repeated non-contrast CT was reported to be unremarkable. However, 5 months later, he presented with a left lower quadrant abdominal wall abscess and back pain. An updated CT showed a linear hyperdensity which was already present in previous scans, causing small bowel perforation, abdominal wall abscess and spondylodiscitis. Emergency laparotomy identified a toothpick causing small bowel perforation. The abdominal wall abscess was incised and drained, and small bowel was repaired.

Trans-colonic foreign body penetration of the retro-hepatic vena cava. Report of a case and review of the literature

Foreign body ingestion is common in mentally impaired adults. Fortunately, the vast majority of all swallowed objects pass through the gastrointestinal tract uneventfully. For patients in whom conservative treatment fails, early endoscopic intervention is required. Surgery is seldom indicated and reports of perforation or penetration of the GI tract are anecdotal. We present a case of a 32 years old mentally impaired patient with a trans-colonic penetration of a foreign body into the retro-hepatic vena cava.

Successful diagnosis and treatment of ingested wooden toothpicks: Two case reports

RATIONALE

Foreign-body ingestion is a common phenomenon and foreign bodies are mostly excreted in stool. Once sharp bodies are ingested without being realized, perforation of intestine is possible and misdiagnosis may be made. We report 2 toothpick ingestion cases that were both diagnosed accurately.

PATIENT CONCERNS

We present 2 cases of middle-aged persons who suffered from abdominal pain. They did not realize and provide any information of having the history of swallowing foreign bodies.

DIAGNOSES

No serious problem was discovered in the examination and blood test. There were somewhere abnormal in computed tomography (CT) images and ultrasound (US). Then a toothpick was found penetrating the wall of intestine into the adjacent viscera in the laparotomy.

INTERVENTIONS

Both patients in the 2 cases were undergone operation to remove the toothpicks.

OUTCOMES

The 2 cases' prognoses were good.

LESSONS

When accepting patients with abdominal pain, suitable examining means and careful observation should be given to find easily ignored lesions. CT is recommended in the diagnostic process of swallowed foreign mass. When there is a vague place, US can be used for further diagnose.

Toothpick ingestion and migration into the liver through the colonic hepatic flexure: case presentation, management, and literature review

The approach to toothpick ingestion and its complications should not be underestimated. The surgeon should be prepared for life-threatening situations such as major vascular involvement, as well as highly specialized and technically challenging procedures, when the hepatic hilum is involved for instance. Referral to tertiary centers is sometimes mandatory.

Gastrointestinal perforation secondary to accidental ingestion of toothpicks: A series case report

RATIONALE

Toothpicks are widely used as a tooth cleaning tool after meals in China. Most of the Chinese toothpicks are made of wood or bamboo with a hard texture and sharp ends. This characteristic has proven to be potentially dangerous when toothpicks are accidentally ingested, as they can cause damage and perforation of the digestive tract and other subsequent complications.

PATIENT CONCERNS

The main clinical complaints of 5 patients in this study were mainly acute or chronic abdominal pain, duration from 2 days to 2 months, 1 case with vomiting, 1 case with fever.

DIAGNOSES

Four cases were initially diagnosed by computed tomography (CT) scan; However, the first case was misdiagnosed as appendicitis so the patient did not undertake a preoperative CT scan and it was diagnosed by laparoscopy.

INTERVENTIONS

All the cases were treated by laparoscopy and the toothpicks were removed successfully.

OUTCOMES

Toothpick-caused digestive perforation was confirmed by laparoscopy in all this 5 cases, the perforation sites were 2 cases at the antrum of stomach, 1 case at the third part of duodenum, 1 case at the ileocecal junction and 1 case at the sigmoid colon. 4 cases had perforation repair . Operative time :48-67 min. Intraoperative bleeding: 25-80 ml. 1 patient had a secondary liver injury. No postoperative complications occurred in all cases. The length of hospital stay was between 4-25 days.

LESSONS

Our case series study suggests that laparoscopy is a safe and feasible surgical procedure for definitive management of digestive tract perforation by toothpick ingestion. We also suggest all the people should have healthy life behaviors and use the toothpicks correctly.

Toothpick-induced aortoenteric fistula presenting as sepsis

Aortoenteric fistulas (AEF) are a rare but life-threatening cause of gastrointestinal (GI) bleeding. We present the case of a primary AEF caused by ingestion of a toothpick by a 47-year-old male. This is the 10th known case in the literature in which a foreign body was found to be the cause of a communication between the aorta and the GI tract. Most foreign objects have been sewing needles; this is the first known case of a toothpick penetration. The patient presented to our institution with polymicrobial sepsis and bilateral pulmonary septic emboli. The patient was successfully treated but required multiple interventions and a prolonged intensive care unit admission.

Toothpick impaction in a sigmoid diverticulum

A 70-year-old woman presented to our emergency department with recurrent episodes of left lower quadrant pain. She subsequently underwent high anterior resection with working diagnosis of acute diverticulitis, but intraoperatively was found to have perforated sigmoid diverticulum due to toothpick impaction. A high index of suspicion is required for diagnosis of toothpick ingestion. Appropriate preoperative investigations such as endoscopy and CT, despite their fairly low sensitivity, should be performed to increase the ability to accurately diagnose this condition and therefore optimise subsequent management.

Toothpick inside the Common Bile Duct: A Case Report and Literature Review

The incidence and prevalence of foreign body (FB) ingestion are difficult to estimate. Unlike other foreign bodies, the ingestion of a toothpick is very uncommon and carries high morbidity and mortality rates. We report a case of a 73-year-old female patient presenting mid-term epigastric pain. Abdominal ultrasound revealed a slightly dilated common bile duct (CBD) and magnetic resonance showed an irregular filling failure in distal CBD and gallstones. Endoscopic Retrograde Cholangiopancreatography revealed major papilla on the edge of a diverticulum and confirmed the distal filling failure. After sphincterotomy, a partially intact toothpick was extracted from the CBD. Neither fistulas nor perforation signs were found. Literature related to foreign bodies and toothpick ingestion was reviewed and some hypotheses to explain the reported case were created. To our knowledge, this is the first report of a toothpick lodged inside the biliary tract.

Toothpick meningitis

A 66-year-old male with a history of hypertension, back pain, diverticulosis and anal fistula presents with acute onset syncopal episodes, worsening back pain, and altered mental status. The patient exhibited considerable leukocytosis but was hemodynamically stable. CT imaging of the head revealed a gas pattern in the posterior fossa and velum interpositum. CT imaging of the abdomen and pelvis revealed a needle-like foreign body traversing the left sacrum to the sigmoid colon. A lumbar puncture revealed meningitis. Flexible sigmoidoscopies were performed without successful visualization of the foreign body. An explorative laparoscopy was successfully performed, enabling retrieval of what was determined to be a wooden toothpick. The patient remained hemodynamically stable with persistent altered mental status and was eventually discharged after completion of antibiotics on day 47 of hospitalization. This case illustrates a rare complication of ingesting a sharp foreign body that was identified by CT of the brain and abdomen/pelvis with successful surgical repair.

Small Bowel Obstruction Caused by the Ingestion of a Wooden Toothpick: The CT findings and a Literature Review

We present a case in which the accidental ingestion of a toothpick caused duodenal perforation and small intestinal obstruction. A 58-year-old man visited our emergency room with acute abdominal pain. Computed tomography (CT) showed obstructive ileus as well as a foreign body penetrating the duodenum, which was identified as a toothpick and removed endoscopically. Unenhanced CT was superior in detecting the object. The patient has been doing well since the operation.