Case 2: A 72-year-old South Korean male was hospitalized with abdominal pain and fever. The fever lasted for 4 days before hospitalization. He had no medical or surgical history. Laboratory testing revealed a white blood cell count of 9950 cells/mm3, hemoglobin count of 12.2 g/dL, and hs-CRP of 9.32 mg/dL. The other laboratory tests reported no specific findings. The patient initially had massive, severe abdominal pain that persisted for a while, followed by continued mild tenderness. There were no other clinical symptoms. An APCT scan revealed that there was a small abscess formation, measuring about 2.5 cm abutting abdominal wall in the right paracolic gutter, and a parasite infestation was ruled out (Fig. 3A). Although he received antibiotic therapy with nothing by mouth for 1 week, follow-up abdomen ultrasonography continued to show an abscess formation with a foreign body (Fig. 4A). After another week with antibiotics therapy and nothing by mouth, a follow-up APCT scan revealed that the presumed abscess had increased in size to about 4.5 cm in the right paracolic gutter with direct invasion of the right anterior abdominal wall muscle (Fig. 3B). Laparoscopic exploration was performed. The laparoscopic view of the abdominal cavity revealed that the about 4 to 5 cm isolated abscess pocket was attached to the intra-abdominal wall and the abscess pocket was separated from the intestine and any organs or structures. When the abscess pocket was removed from the abdominal wall using a harmony scalpel, a 4 cm foreign body that resembled a toothpick appeared in the abscess pocket (Fig. 4B). Abscess pocket was a round shape surrounding the fatty tissue (Fig. 5A). There was sharp foreign body like toothpick (Fig. 5B). No perforation of the intestine was found, and no abdominal findings were seen. After removal of the abscess pocket, the final pathological analysis revealed acute and chronic inflammation with granulation tissue formation and fat necrosis. The patient recovered well after surgery and was discharged on postoperative day 4. Like the patient in Case 1, he had not eaten fish or any foreign bodies but had used toothpicks frequently, although he was not aware that he had ingested one. In this patient, it is presumed that the wound closed spontaneously after intestinal perforation, although the location of the intestinal perforation was not identified.
Toothpick ingestion is a relatively rare event that can result in serious gastrointestinal injuries that lead to peritonitis, sepsis, or even death. It is interesting to note that a 4-year survey performed in the United States found 8176 reported toothpick-related gastrointestinal injuries each year, a rate of 3.6 per 100,000 person-years. Perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than 1% of cases involving ingested bodies, and toothpicks are involved in less than 0.1%. Unless the foreign bodies were swallowed intentionally, many patients who ingested them fail to remember the event from which the symptoms of perforation develop, and this makes diagnosis problematic. Most patients swallow toothpicks while eating their meals and are unaware of having done so. In the 2 cases that are reported here, both patients failed to remember or were unaware of having swallowed any foreign bodies such as toothpicks. Potential complications that are commonly reported as a result of ingesting toothpicks include gastrointestinal bleeding, subphrenic abscesses, sepsis obstructions, gastrointestinal perforations, and fistula. A sharp toothpick that is ingested travels around the gastrointestinal tract, and this can injure the lumen and cause perforations. One article reports that the most frequent locations of such perforations are the rectum and sigmoid colon (54.5%) and the terminal ileum (21.2%). In present Case 1 that is reported above, the perforation site was the sigmoid colon. In present Case 2, an intra-abdominal abscess formed after intestinal perforation had occurred following toothpick ingestion. It is interesting to note that in both cases the toothpicks were outside the intestinal lumen and were present in the abscess. In Case 2, the isolated abscess pocket was located in the intra-abdominal wall, was not adjacent to the other bowel, and was not attached to the bowel.
Establishing the correct diagnosis of intestinal perforation caused by toothpick ingestion is very difficult because of the low sensitivity rate and accuracy rate of diagnostic investigations. The sensitivity of computed tomography (CT) scans when detecting an ingested toothpick is only 42.6%. A careful interpretation of CT scans can improve the detection of accidental toothpicks. CT scans are useful for acquiring clinical information, such as the location of the toothpick and the area of tissue damage. In addition, CT scans can determine the presence of a perforation and the extent of intra-abdominal inflammation either with or without abscess formation. In some cases, the toothpicks are detected by ultrasonography. In present Case2, ultrasonography was performed and showed an abscess formation with a foreign body like toothpick, although this was misdiagnosed as a parasite.
Treating intestinal perforation caused by toothpick ingestion requires surgical management. The removal of a toothpick and the primary repair of the perforation site or resection of the perforated bowel are needed for complete treatment. For patients who do not have a lot of inflammation or symptoms of peritonitis, treatment by performing only endoscopic removal of a toothpick within the lumen of bowel has proven successful. Present Case 1 involved resection of the sigmoid colon because of the perforation and resulting peritonitis and removal of the abscess pocket that contained the toothpick. In conclusion, these patients failed to remember the events in which they ingested toothpicks, and these foreign bodies can cause gastrointestinal perforations, which generally require surgical treatment to remove the toothpicks.
Conceptualization: Dae Ro Lim, Eung Jin Shin.
Data curation: Dae Ro Lim, Taehyung Kim.
Investigation: Dae Ro Lim, Jung Cheol Kuk, Taehyung Kim.
Methodology: Taehyung Kim.
Resources: Dae Ro Lim, Taehyung Kim.
Software: Eung Jin Shin.
Supervision: Dae Ro Lim, Jung Cheol Kuk, Eung Jin Shin.
Validation: Jung Cheol Kuk, Eung Jin Shin.
Visualization: Dae Ro Lim, Eung Jin Shin.
Writing – original draft: Dae Ro Lim.
Writing – review & editing: Dae Ro Lim, Jung Cheol Kuk, Taehyung Kim, Eung Jin Shin.
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Keywords:Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.
intestinal perforation; surgery; toothpick