The case of the forgotten toothbrush

Abstract

INTRODUCTION

Although foreign body ingestion is relatively common, toothbrush swallowing is rare. A diagnosis of small-bowel perforation, caused by a sharp or pointed foreign body, is rarely made preoperatively because the clinical symptoms are usually nonspecific and can mimic other surgical conditions, such as appendicitis and diverticulitis.

PRESENTATION OF CASE

We report a case of a swallowed toothbrush which passed past the pylorus and perforated the terminal ileum. The patient however presented with a fluctuant mass in the left iliac fossa, pyrexia and generalised tenderness mimicking a diverticular abscess.

DISCUSSION

Ingestion of a foreign body is commonly encountered in the clinic among children, adults with intellectual impairment, psychiatric illness or alcoholism, and dental prosthetic-wearing elderly subjects. However, toothbrush swallowing is rare, with only approximately 40 reported cases.

CONCLUSION

Bowel perforation by foreign bodies can mimic acute appendicitis and should be considered in differential diagnoses. Clinically, patients often do not recall ingesting the foreign body, which makes the clinical diagnosis more challenging, and a correct diagnosis is frequently delayed. Several radiological investigations, such as small-bowel series, ultrasonography, and computed tomography scans, may lead to the correct diagnosis, but in most patients, the diagnosis is not confirmed until the surgical intervention has been performed.

1. Introduction

A variety of foreign bodies are seen on abdominal radiographs in emergency departments. Most foreign-body ingestion is accidental, but there may be contributory factors such as mental disorder, bulimia, alcoholism, and prison incarceration. When foreign bodies are ingested, they usually pass spontaneously through the entire alimentary tract and out in the faeces. Perforation of the gastrointestinal tract is a well-recognized complication of foreign-body ingestion and the ileum is the most common site of perforation.¹ Toothbrush ingestion is uncommon, but requires prompt medical attention.

2. Case report

A 45 year old male with learning difficulties and history of schizophrenia presented with a fluctuant mass in the left iliac fossa, pyrexia and generalised tenderness mimicking a diverticular abscess. His initial blood tests revealed a white cell count of 17 × 10⁹/L and a C-reactive protein (CRP) level of 89 mg/L. We include his initial abdominal X ray (Fig. 1), a reconstructed CT image (Fig. 2) and findings at laparotomy (Fig. 3). He had completely forgotten to tell anyone about the toothbrush he had swallowed 3 years prior. The toothbrush had managed to pass past the pylorus and perforated the terminal ileum. Although 80% of ingested foreign bodies pass spontaneously,² there is only one report regarding swallowed toothbrushes passing past the pylorus.³

Fig. 1.

Fig. 2.

Fig. 3.

3. Discussion and conclusion

Ingestion of a foreign body is commonly encountered in the clinic among children, adults with intellectual impairment, psychiatric illness or alcoholism, and dental prosthetic-wearing elderly subjects.² However, toothbrush swallowing is rare, with only approximately 40 reported cases.⁴ It was reported that a toothbrush shows a characteristic radiographic image with parallel rows of short metallic radiodensities due to the metallic plates that hold the bristles in place.⁵ Unlike most other foreign bodies, there are no reports of swallowed toothbrushes passing spontaneously.⁴ In order to avoid complications such as pressure necrosis causing gastritis, ulceration and perforation, prompt intervention is required. An initial extraction strategy to consider is endoscopy by a skilled technician, and the first successful performance of this procedure was reported by Ertan et al..⁶ If endoscopic removal is not possible and particular complications are not present, a laparoscopic approach may be an alternative to laparotomy.⁷

Bowel perforation by foreign bodies can mimic acute appendicitis and should be considered in differential diagnoses. Clinically, patients often do not recall ingesting the foreign body, which makes the clinical diagnosis more challenging, and a correct diagnosis is frequently delayed. Several radiological investigations, such as small-bowel series, ultrasonography, and computed tomography scans, may lead to the correct diagnosis, but in most patients, the diagnosis is not confirmed until the surgical intervention has been performed.

Conflicts of interests

None.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contribution

All authors contributed to the writing of the case report.