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

Abstract

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.

Introduction

Foreign body ingestion and food bolus impaction are common complaints in the emergency department (ED). In most instances (60%-90%), the ingested object passes spontaneously through the gut without an incident.^1-3 Toothpick ingestion is infrequent and a medical emergency. With its sharp-pointed ends, a toothpick can cause bowel perforation, gastrointestinal bleeding, abscesses,^2,3 or even death if intervention is delayed. ⁴ Toothpick migration into the adjacent viscera has also been reported in some cases, with grave consequences.^4,5 Here, we present an intriguing case of unnoticed toothpick ingestion causing a contained gastric perforation. The toothpick was successfully retrieved via upper endoscopy, and the patient was discharged without further complications.

Case Report

A 79-year-old female with a past medical history of hypertension, hyperlipidemia, and peptic ulcer disease presented to the ED complaining of sharp epigastric pain for 11 days. Her pain was associated with nausea and worsened with food intake and change in position. She denied vomiting, dysphagia, odynophagia, early satiety, diarrhea, constipation, melena, or hematochezia. Of note, the patient was evaluated at another facility a week prior for the same complaint, but a computed tomography (CT) scan of the abdomen and pelvis showed no abnormalities.

In the ED, the patient appeared in mild distress due to pain. Vital signs were significant only for elevated blood pressure of 152/66 mm Hg. Her abdomen was soft, obese, and tender to touch in the epigastrium without guarding, rigidity, or rebound tenderness. The rest of the examination was unremarkable. Laboratory values were notable for leukocytosis with a white blood cell count of 12.0 × 10³/mm³, but the rest of the cell lines, liver function panel, electrolytes, and serum lipase were within normal ranges. Computed tomography of the abdomen and pelvis revealed marked antrum thickening with ulcer along the posterior gastric wall (mimicking gastric neoplasm) and contained perforation (Figure 1). The patient was admitted to the medical floors with symptomatic management for the nausea and abdominal pain and kept nil per os (NPO or nothing by mouth).

Figure 1.

Computed tomography of the abdomen and pelvis with contrast showing gastric wall thickening (red arrow).

Later in the day, a rapid response team was called for massive hematemesis, and the patient was intubated for airway protection. Hemoglobin dropped from 11.5 g/dL to 8.8. g/dL, and one unit of packed red blood cells was given. Esophagogastroduodenoscopy (EGD) was performed, which revealed a gastric ulcer in the antrum with blood clots and fresh blood and an embedded toothpick in the middle (Figure 2). The toothpick was extracted endoscopically using Raptor forceps with the leading edge pointed distally. A relook endoscopy showed no bleeding at the site of ulceration and normal duodenum. The patient remained intubated postprocedure and was admitted to the intensive care unit (ICU) for closer monitoring. Her family later confirmed that the patient had used toothpicks when cooking meat in the oven. Even so, the patient had no recollection of the swallowing event.

Figure 2.

Endoscopic image showing an adherent blood clot in the fundus (panel 1), gastric ulcer in the antrum with an embedded toothpick in the middle (panels 2 and 4). Panel 3 shows the gastric ulcer after the removal of the toothpick.

After the procedure, we kept the patient on maintenance fluids, pantoprazole 40 mg, intravenous (IV), twice daily (BID), and sucralfate, every 6 hours (QID). No surgical intervention was needed. We also empirically treated her with piperacillin-tazobactam and micafungin for 5 days given the microperforation and an increased risk of peritonitis. Hemoglobin remained stable throughout her hospital stay with no further episodes of hematemesis or melena. The patient was extubated on day 2 after the foreign body removal, and diet was advanced as tolerated. The patient benefited from inpatient physical therapy, and she endorsed flatus and regular bowel movements. On discharge, she was prescribed pantoprazole 40 mg daily, sucralfate 10 ml QID, and bowel regimen as needed. The patient was educated about her condition and urged to return to the ED if the abdominal pain worsened or if she experienced hematemesis, chest pain, palpitations, lethargy, dark stools, or any other new concerns. She had no active complaints at a 2-week follow-up appointment and tolerated a regular diet.

Discussion

Toothpick ingestion is a rare and life-threatening event with a mortality rate of 9% to 12%. ⁶ Up to 1600 American adults are estimated to die annually due to complications associated with ingested foreign bodies. ⁷ Risk factors for toothpick swallowing include male gender, cooking with toothpicks, habitual chewing of toothpicks, and alcohol intoxication. ⁴ Ingested toothpicks often get lodged in hollow, angled, or narrowed lumens such as the stomach, duodenum, ileocecal area, appendix, and sigmoid colon. ³

Most toothpick ingestions occur at mealtimes, and signs and symptoms can be instant or delayed. The patient presentations also vary from asymptomatic, acute abdomen to hemorrhagic shock.

Our patient, for example, presented to the ED complaining of sharp epigastric pain and nausea; symptoms that were initially attributed to her peptic ulcer disease. Toothpick ingestions can cause gastrointestinal bleeding, which may manifest as melena, hematochezia, or hematemesis. Bowel obstruction, perforations, and peritonitis have also been reported in some cases.^1-5 As noted by Majjad et al, ⁸ toothpick ingestion can simulate other acute pathologies such as appendicitis, and a delay in treatment can lead to worse outcomes. Ingested toothpicks are commonly missed on routine imaging due to the radiolucent nature of the object. ⁹ As seen in this case, the initial CT scan of the abdomen failed to pick up the impacted toothpick, and the patient was discharged home, only to present a week later with complications. Similarly, the repeat CT scan missed the foreign body and rather revealed gastric wall thickening suggestive of a gastric neoplasm.

Toothpick ingestion is a medical emergency requiring urgent intervention. Endoscopy is a primary diagnostic and therapeutic tool for managing foreign bodies, including swallowed toothpicks. Endoscopy can be employed with a retrieval basket, net, tripod, polypectomy snare, latex rubber hood, overtube, or transparent cap.^10,11 A combination of these accessories can be used in challenging cases. Perforations may be closed with standard clips or over the scope clips. ¹² Endoscopy has an efficacy rate greater than 95%, and procedural complications such as mucosal ulceration, bleeding, perforation, or infection are infrequent. ¹⁰ While the American gastroenterology societies lack clear and concise guidelines on the management of ingested toothpicks, the European Society of Gastrointestinal Endoscopy (ESGE) recommends urgent (within 24 hours) therapeutic EGD to avert further complications. ⁷ Colonoscopy has been used in distally migrated toothpicks with equal success. Sarici et al ¹ reported a series of 2 cases of colonic perforation due to toothpick ingestion successfully managed via colonoscopy.

Surgical intervention is indicated for gut perforations and migrated toothpicks. In a retrospective review of 136 cases of toothpick ingestion, Steinbach et al ⁶ found that laparotomy was performed in 66 cases. Notably, laparotomy was indicated in cases where the toothpicks migrated distally or into the surrounding organs. Although infrequent, toothpick migration to the liver, blood vessels, pancreas, and spleen has been reported in the literature, and the management must be organ-specific. ⁶ Laparoscopic surgery can be employed where feasible for quicker recovery and fewer complications. Because toothpick ingestion can be asymptomatic, it can be an incidental finding during surgery. Al-Khyatt et al ³ described a unique case of toothpick impaction in the porta hepatis as an incidental finding during laparoscopic cholecystectomy for symptomatic cholelithiasis.

Conclusion

Toothpick ingestion is a rare event that is associated with a morbidity and mortality. Toothpicks are radiolucent and may be missed on X-ray or CT scans. Endoscopy is both a diagnostic and therapeutic tool for toothpick ingestion. Surgery is indicated when there is a concern for gastrointestinal perforation or damage to the surrounding vascular organs.