Toothpick Perforation of the Small Bowel

A 39-year-old male presented to our gastroenterology clinic with a 6 month history of intermittent cramping and sharp bilateral lower quadrant abdominal pain. He reported associated constipation, bloating, infrequent nausea and vomiting, occasional exacerbation of pain with food intake, and a 10 pound weight loss. He had been evaluated by his primary care physician 4 months earlier. At that time, his evaluation was notable for a white blood cell count of 15,000/mm3. Comprehensive metabolic panel and thyroid stimulating hormone were within normal limits and an abdominal x-ray showed a normal bowel gas pattern. At the time of our evaluation in the gastroenterology clinic, he was well-appearing and in no distress. He had no significant past medical history and was not taking any medications. Abdominal examination revealed normoactive bowel sounds, moderate tenderness and mild guarding to palpation in the right lower quadrant without rebound. His white blood cell count was significantly elevated at 25,300/mm3. A computed tomography scan of the abdomen and pelvis showed a linear foreign body extending from the lumen of a distal loop of small bowel through the bowel wall with minimal surrounding inflammation (Figure A, red circle). The patient was taken to the operating room and underwent an exploratory laparotomy which revealed a wooden toothpick perforating the small bowel at both ends of the toothpick with significant surrounding inflammation and adhesions (Figure B). He required lysis of adhesions and small bowel resection with primary stapled anastomosis. Postoperatively, the patient admitted a history of chewing toothpicks and was not aware that he had swallowed a toothpick. However, his wife reported that he often fell asleep with a toothpick in his mouth. Toothpick perforations of the gastrointestinal tract are uncommon, with an incidence of approximately 0.2 per 100,000 persons annually in the U.S.1 but are associated with a high mortality rate of 20–80%.2 The most common site of injury is the duodenum followed by the sigmoid colon and ileum. Imaging studies vary in their sensitivity in detecting toothpicks, but are often inadequate. Definitive diagnosis is most commonly made at the time of surgical exploration. Li et al reported that the duration of symptoms before diagnosis ranged from 1 day to 9 months and that the diagnosis was established by laparotomy in 53% of cases as opposed to imaging studies in 14%.2 This case highlights a rare cause of small bowel injury and the complications and mortality associated with it.