Citation: Reginelli A, Liguori P, Perrotta V, Annunziata G, Pinto A: Computed tomographic detection of toothpick perforation of the jejunum: case report and literature. Radiology Case Reports. [Online] 2007;2:52.
Copyright: © Alfonso Reginelli. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 2.5 License, which permits reproduction and distribution, provided the original work is properly cited. Commercial use and derivative works are not permitted.
Abbreviations: CT, computed tomography
Alfonso Reginelli (email@example.com), Valeria Perrotta and Giuseppina Annunziata are from Second University of Naples, Section of Radiology, Department of “Magrassi-Lanzara”, Naples, Italy
Pasquale Liguori and Antonio Pinto are from the Department of Radiology, Cardarelli Hospital, Naples, Italy
Foreign body ingestion is commonly encountered in the emergency department. Although in most cases, the ingested object will pass uneventfully in the feces , ingestion of sharp foreign bodies such as dental plates, sewing needles, toothpicks, fish bones and chicken bones carries increased risk of gastrointestinal perforation [2-4].
The use of toothpicks as both tooth-clearing implements and eating utensils increase the likelihood of toothpick unintentional ingestion .
Toothpicks account for 9% of reported foreign bodies ingested . These pointed wooden bodies when accidentally swallowed are associated with higher risk of complications, such as gastric, small bowel or colonic perforation, obstruction, colonic impaction, gastrointestinal bleeding, subphrenic abscess, fistula formation, sepsis and/or death due to the damaged caused by the sharp pointed ends [7-9].
Unfortunately, many patients who ingested such objects fail to remember the mis-swallowing event when symptoms of perforation develop, making diagnosis problematic.
We present a case of jejunal perforation secondary to an ingested wooden toothpick correctly diagnosed with Computed Tomography (CT).
A 61-year-old man with no previous history of related medical problems or surgery presented to our emergency department with acute abdominal pain of 7h duration. His abdomen was distended and painful on percussion. Liver percussion was absent. The vital signs were: blood pressure 130/70 mm Hg, temperature 38.5°C and pulse rate 100/min.
Normocytic anemia, marked elevation of erythrocyte sedimentation rate and a slight leukocytosis were found in laboratory examinations. Plain abdominal film was normal.
A CT scan of the abdomen showed a small radiopaque foreign body (Figure 1) lodged within the small bowel.At the time of exploratory laparotomy, a double-pointed hollow toothpick was seen perforating a proximal jejunal loop.
Figure 1 A, B and C. Abdominal Computed Tomography (three contiguous sections) showing the presence of a toothpick (arrow) within an intestinal loop. [Powerpoint Slide]
The toothpick was removed and the puncture site was closed. The peritoneal cavity was lavaged with warm normal saline. The patient had an unremarkable recovery after seven days of antibiotics and was discharged from the hospital after ten days. In retrospect, the patient did not recall swallowing the toothpick.
A perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than 1% of ingested bodies [10,11]. Toothpicks are involved in less than 0.1% . Toothpicks, however, by their nature are more likely to cause intestinal perforations than other objects as they are long and pointed at both ends. The rate of perforation could be as high as 30% . The incidence of “toothpick-related injuries” to internal organs is estimated at 0.2/100000 population .
A one-year survey in the United States found 8,176 toothpick-related injuries, with 5% involving internal organ .
Several factors are strongly associated with toothpick ingestion, including impaired palatal sensation (alcoholics, dentures), elderly patients (dementia), children, food containing toothpicks, and the habitual “chewing” of toothpicks .
Frequently patients do not remember ingesting toothpicks or may recall the incident only after the diagnosis is made.
Most patients (70%) present with abdominal pain , while 7% of patients present with gastrointestinal bleeding . Moreover perforation of the gastrointestinal tract due to the ingestion of a toothpick can cause acute symptoms with signs of peritonitis, but also with spontaneous closure of the puncture hole can determine later complications [16-25].
Peristalsis of the intestinal tract will propel the toothpick through the intestinal wall, which can lead to migration to other organs  close to the perforating site, thereby demonstrating a very different clinical pathology such as constrictive pericarditis .
The involvement of pleura , ureter , and bladder [30-32] in such foreign body migration have all been previously reported, and in some cases described, the toothpick caused a fistula with a major blood vessel, such as the aorta or inferior vena cava [8, 33-37].
Some cases of liver abscess due to the ingestion of a toothpick have also been described [4,38, 39-44] as well as a case of retroperitoneal and thigh cellulitis secondary to colonic perforation due to toothpick ingestion .
Early diagnosis and retrieval of a toothpick involved in gastrointestinal tract perforation is critical for reducing morbidity and mortality . Along with the variability of the clinical presentation, the often radiolucent nature of ingested objects further impedes preoperative diagnosis.
A definitive diagnosis is frequently made during an explorative laparotomy, followed by endoscopy, imaging studies and autopsy . However, the modality used to detect the toothpick depends on its location. Gastroduodenoscopy and colonoscopy are the preferred choices for the assessment of objects lodged in upper or lower gastrointestinal tract because of their capacity of visualization of areas involved in the perforation [47-52].
These techniques also allow ingested objects to be removed once identified. Unfortunately, the sensitivity of these techniques can be reduced in some chronic cases of perforation or migration with healed mucosa. In addition, endoscopy is less feasible in some cases with extraluminal migration and does not allow examination of the mid-gut . Imaging studies are optimal for such cases: a preoperative diagnosis using plain film, ultrasound, computed tomography and upper gastrointestinal studies has been reported [38, 54,55].
Because the hollow toothpick can function as a fistula between gastric and peritoneal cavity, air and the gastric contents can thus flow outside the stomach. The clinical picture is that of acute peritonitis, and on a plain abdominal X-ray free air can be shown , but not in all cases, because the radiological detection of ingested wooden objects using plain abdominal film is limited due to the nature of non-radiopaque nature of wood .
Nevertheless, ingested toothpicks can be hyperdense on CT examination, as in our case (Figure 1), and exhibit better resolution on CT compared with conventional X-ray study.
Computed tomographic study in cases of toothpick ingestion can also determine the presence of perforation and the extent of intra-abdominal inflammation either with or without abscess formation .
Removal of a toothpick and subsequent suturing of the puncture site is a simple and relatively minor surgical procedure, which may have a lower morbidity and mortality as compared to other causes of gastric perforation. A precaution to observe is the potential danger that one of the members of the operating team might perforate a finger .
Although toothpicks may be viewed as relatively benign objects, the review of the literature clearly demonstrate that toothpick ingestion may cause severe, sometimes fatal, gastrointestinal and non gastrointestinal complications.
The possibility and the potential severity of these complications strongly recommend urgent emergency consultation after accidental toothpick ingestion.
Moreover, a hollow toothpick perforation must be considered in any patient with symptoms of intestinal perforation, even when there is no history of swallowing toothpicks.
1. Cockerill FR 3rd, Wilson WR, Van Scoy RE. Traveling toothpicks. Mayo Clin Proc 1983; 58: 613-616. [PubMed]
2. Abel RM, Fischer JE, Hendren WH. Penetration of the alimentary tract by a foreign body with migration to the liver. Arch Surg 1971; 102: 227-228. [PubMed]
3. Tsuboi K, Nakajima Y, Yamamoto S. A case of an intrahepatic fish bone penetration – possibility of the preoperative diagnosis by CT scan. Arch Jpn Chir 1981; 50: 899-903. [PubMed]
4. Pederson VM, Geerdsen JP, Bartholdy J, Kjaergaard H. Foreign body perforation of the gastrointestinal tract with formation of liver abscess. Ann Chir Gynecol 1986; 75: 245-246. [PubMed]
5. Malamud D, Murphy MH. Martini toothpick warning. N Engl J Med 1986; 315: 1031-1032. [PubMed]
6. Lellouche N, Ayoub N, Bruneel F, et al. Thigh cellulitis caused by toothpick ingestion. Intensive Care Med 2003; 29: 662-663.[CrossRef]
7. Hewett PJ, Young JF. Toothpick injuries to the gastrointestinal tract. Aust N Z J Surg 1991; 61: 35-37. [PubMed]
8. Dicicco BS, Heit HA, Peterson JE, Harshaw WG, Cooper JN. Massive bleeding due to arterial-enteric fistula from an ingested toothpick. J Clin Gastroenterol 1985; 7: 292-295. [PubMed]
9. Jernigan PA, Mullin GT Jr. Intestinal fistula from a toothpick. Minn Med 1979; 62: 321-322. [PubMed]
10. McPherson R, Karlan M, Williams R. Foreign body perforation of the intestinal tract. Am J Surg 1957; 94: 564-566. [PubMed]
11. Henderson CT, Engel J, Schlesinger P. Foreign body ingestion: review and suggested guidelines for management. Endoscopy 1987; 19: 68-71. [PubMed]
12. Tenner S, Wong RCK, Carr-Locke D, Davis SK, Farraye FA . Toothpick ingestion as a cause of acute and chronic duodenal inflammation. Am J Gastroenterol 1996; 91:1860-1862. [PubMed]
13. Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984; 252: 796-797. [PubMed]
14. Konig PS, Kronenberg F, Joannidis M, Dietl P, Lhotta K. Recurrent abdominal pain caused by a toothpick in a CAPD patient. Adv Perit Dialysis 1991; 7: 96. [PubMed]
15. Li SF, Ender K. Toothpick injury mimicking renal colic: case report and systematic review. J Emerg Med 2002; 23: 35-38. [PubMed]
16. Porcu A, Dessanti A, Feo CF, Dettori G. Asymptomatic gastric perforation by a toothpick. A case report. Dig Surg 1999; 16: 437-438. [PubMed]
17. Wiest JW, Follette DM, Traverso LW. Toothpick perforation of the duodenum. West J Med 1980; 132: 157-159. [PubMed]
18. Hashmi MA, Srinivas D, Brimm C, Sorokin JJ, Levine SM. Toothpick perforation of the duodenum. J Clin Gastroenterol 1983; 5: 339-341. [PubMed]
19. Greenspan L, Abramovitch A, Tomarken J, Cohen Z. Perforation of a Meckel’s diverticulum by a foreign body. Can J Surg 1983; 26: 184-185. [PubMed]
20. Nash PA, Cregan PC. Perforation of the gastrointestinal tract by a toothpick. Med J Aust 1987; 147: 415-416. [PubMed]
21. Blankfield RP, Kelly RB. Toothpick perforation mimicking jejunal lymphoma. Postgrad Med 1989; 86: 265-266. [PubMed]
22. Hauser H, Pfeifer J, Uranus S, Klimpfinger M. Perforation of the cecum by a toothpick. Case report and review of the literature. Langenbecks Arch Chir 1994; 379: 229-232. [PubMed]
23. Kaufman E, Sommers E. Sigmoid colon perforation: result of accidental swallowing of a toothpick. Oral Surg Oral Med Oral Pathol 1984; 58: 535-536. [PubMed]
24. Callon RA Jr, Brady PG. Toothpick perforation of the sigmoid colon: an unusual case associated with Erysipelothrix rhusiopathiae septicemia. Gastrointest Endosc 1990; 36: 141-143. [PubMed]
25. O’ Gorman MA, Boyer RS, Jackson WD. Toothpick foreign body perforation and migration mimicking Crohn’s disease in a child. J Pediatr Gastroenterol Nutr 1996; 23: 628-630. [PubMed]
26. Peters TG, Locke JR, Weight GR. Suppurative pylephlebitis caused by toothpick perforation. South Med J 1988; 81: 414-415. [PubMed]
27. Meyns BP, Faveere BC, Van de Werf FJ, Dotremont G, Daenen WJ. Constrictive pericarditis due to ingestion of a toothpick. Ann Thorac Surg 1994; 57: 489-490. [PubMed]
28. Jenson AB, Fred HL. Toothpick pleurisy. JAMA 1968; 203: 988. [PubMed]
29. Plavcan WG, McWilliams WA. Toothpick obstruction of the ureter. J Urol 1988; 139: 114-115. [PubMed]
30. O’Dea MJ, Malek RS. Foreign body in bladder and perivesicular inflammation masquerading as pelvic lipomatosis. J Urol 1976; 116: 669-670. [PubMed]
31. Eckford SD, Persad RA, Brewster SF et al: Intravesical foreign bodies: five-year review. Br J Urol 1992; 69: 41-45. [PubMed]
32. Alagiri M, Rabinovitch HH. Toothpick migration into bladder presents as abdominal pain and hematuria. Urology 1998; 52: 1130-1131. [PubMed]
33. Justiniani FR, Wigoda L, Ortega RS. Duodenocaval fistula due to toothpick perforation. JAMA 1974; 227: 788-789. [PubMed]
34. Schwartz JT, Graham DY. Toothpick perforation of the intestines. Ann Surg 1977; 185: 64-66. [PubMed]
35. Fry D, Flint LM, Richardson JD. Aorticoduodenal fistula secondary to a toothpick. J Ky Med Assoc 1978; 76: 441. [PubMed]
36. deSa LA, Roddie ME, Williamson RC. Fatal duodenocaval fistula resulting from a giant peptic ulcer. Case report. Acta Chir Scand 1990; 156: 647-650. [PubMed]
37. Allen B, Krupski WC, Wylie EJ. Toothpick perforation of the inferior vena cava. West J Med 1983; 138: 727-730. [PubMed]
38. Rioux M, Langis P. Sonographic detection of clinically unsuspected swallowed toothpicks and their gastrointestinal complications. J Clin Ultrasound 1994; 22: 483-490. [PubMed]
39. Rafizadeh F, Silver H, Fieber S. Pyogenic liver abscess secondary to a toothpick penetrating the gastrointestinal tract. J Med Soc N J 1981; 78: 377-378. [PubMed]
40. Bloch DB. Venturesome toothpick: a continuing source of pyogenic hepatic abscess. JAMA 1984; 252: 797-798. [PubMed]
41. Tsui BC, Mossey J. Occult liver abscess following clinically unsuspected ingestion of foreign bodies. Can J Gastroenterol 1997; 11: 445-448. [PubMed]
42. Zambrana JL, Garcia-Gutierrez JA, Diez F. Subphrenic abscess related to the ingestion of a toothpick. N Engl J Med 1998; 338: 133-134. [PubMed]
43. Drnovsek V, Fontanez-Garcia D, Wakabayashi MN, Plavsic BM. Gastrointestinal case of the day. Pyogenic liver abscess caused by perforation by a swallowed wooden toothpick. Radiographics 1999; 19: 820-822. [PubMed]
44. Kanazawa S, Ishigaki K, Miyake T, et al. A granulomatous liver abscess which developed after a toothpick penetrated the gastrointestinal tract: report of a case. Surg Today 2003; 33: 312-314. [PubMed]
45. Bee DM, Citron M, Vannix RS, et al. Delayed death from ingestion of a toothpick. N Engl J Med 1989; 320: 673. [PubMed]
46. Steenvoorde P, Moues CM, Viersma JH. Gastric perforation due to the ingestion of a hollow toothpick: report of a case. Surg Today 2002; 32: 731-733. [PubMed]
47. Darby JP. Fiberendoscopic removal of non-radiopaque foreign body (toothpick) from the stomach. Gastrointest Endoscopy 1974; 21: 31-32. [PubMed]
48. Honaas TO, Shaffer EA. Endoscopic removal of a foreign body perforating the duodenum. Can Med Assoc J 1977; 116: 164-169. [PubMed]
49. Meltzer SJ, Goldberg MD, Meltzer RM, Claps F. Appendiceal obstruction by a toothpick removed at colonoscopy. Am J Gastroenterol 1986; 81: 1107-1108. [PubMed]
50. Monkemuller KE, Patil R, Marino CR. Endoscopic removal of a toothpick from the transverse colon. Am J Gastroenterol 1996; 91: 2438-2439. [PubMed]
51. Over HH, Tozun N, Avsar E. Toothpick impaction: treatment by colonoscopy. Endoscopy 1997; 29: S60-61. [PubMed]
52. Reddy SK, Griffith GS, Goldstein JA, Stollman NH. Toothpick impaction with localized sigmoid perforation: successful colonoscopic management. Gastrointest Endosc 1999; 50: 708-709. [PubMed]
53. Cheung YC, Ng SH, Tan CF, Ng KK, Wan YL. Hepatic inflammatory mass secondary to toothpick perforation of the stomach: triphasic CT appearances. Clin Imaging 2000; 24: 93-95. [PubMed]
54. Strauss JE, Balthazar EJ, Naidich DP. Jejunal perforation by a toothpick: CT demonstration. J Comput Assist Tomogr 1985; 9: 812-814. [PubMed]
55. Guber MD, Suarez CA, Greve J. Toothpick perforation of the intestine diagnosed by a small bowel series. Am J Gastroenterol 1996; 91: 789-791. [PubMed]
56. Pinto A, Muzj C, Stavolo C, Pepe M, Cinque T, Romano L. Pictorial essay: foreign bodies of the gastrointestinal tract in emergency radiology. Radiol Med 2004; 107: 145-154. [PubMed]
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