Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:190   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   


 
CASE REPORT Table of Contents   
Year : 2010  |  Volume : 3  |  Issue : 4  |  Page : 401-402
An unusual presentation of toothpick penetration of colon


1 Department of Surgery, SMHS Hospital, Srinagar, Kashmir, India
2 Department of General Medicine, SKIMS, Srinagar, India

Click here for correspondence address and email

Date of Submission17-Jan-2010
Date of Acceptance28-Jan-2010
Date of Web Publication28-Sep-2010
 

   Abstract 

This case report presents the delayed unusual presentation of plastic toothpick penetrating transverse colon 3 months after ingestion with localized peritonitis. Role of omentum "policeman of abdomen" for salvage is highlighted. Careful observation and long-term lookup for any neglected ingested foreign body are stressed. The delayed presentation can be sometimes proving as a surgical emergency.

Keywords: Dementia, toothpick, old age

How to cite this article:
Wani I, Wani SA, Mir S, Parra K. An unusual presentation of toothpick penetration of colon. J Emerg Trauma Shock 2010;3:401-2

How to cite this URL:
Wani I, Wani SA, Mir S, Parra K. An unusual presentation of toothpick penetration of colon. J Emerg Trauma Shock [serial online] 2010 [cited 2019 May 27];3:401-2. Available from: http://www.onlinejets.org/text.asp?2010/3/4/401/70773



   Introduction Top


An 82-year-old man, with dementia, presented to the emergency department with right lower abdominal pain, nausea, vomiting, constipation, and fever of 3 days duration. His vital signs were normal, except a temperature of 100°F. The only positive findings on his clinical examination were rebound tenderness and guarding in a right lower abdomen. Other than a leukocytosis of 10,500/mm 3 , with 88% neutrophils, his blood urea and serum creatinine were 40 mg/dL and 1.2 mg/dL, respectively. His urine analysis, metabolic profile, and serum amylase levels were normal. Computerized tomography of abdomen revealed the presence of perforated appendicitis. The patient underwent emergency laparotomy where it was noticed that the omentum was adherent to the antimesenteric border of a transverse colon in a right lower quadrant, and the appendix looked normal. Further exploration of the abnormally noticeable omentum revealed a yellow toothpick of 0.5 cm thick emanating from the organized omental lump, emerging about 5 cm from the hepatic flexure of a transverse colon [Figure 1] and [Figure 2]. The toothpick was extracted, and the patient made an uneventful recovery. Toothpicks in the gastrointestinal tract have a tendency to lodge in a location where there is an anatomic sphincter, acute angulations, physical narrowing prior surgery, or congenital gut malformation. Predisposing factors for this malady are persons with low IQ, personality disorders, those wearing artificial dentures, and alcoholics, callousness during toothpick use, palatal insensitivity, and pediatric age group. Dementia sometimes may create unawareness and loss of recollection while swallowing a toothpick which may prove challenging to reach a fast diagnosis. Ingested toothpicks are notorious for manifesting as a gastrointestinal bleeding, gut obstruction, bowel perforation, sepsis hemorrhage, and death. [1] Toothpicks have been reported to have the highest rate of impaction and perforation (9%). [2] Perforations of the gastrointestinal tract by ingested toothpicks are rare, with an annual rate of 0.2 per 100,000 persons. [3] Toothpick-related perforations are reported throughout the gastrointestinal tract, including the stomach, duodenum, small bowel, Meckel's diverticulum, appendix, cecum, sigmoid colon, and rectum, with complications. Symptoms and signs associated with toothpick perforation mimic several intra-abdominal diseases, including diverticulitis, appendicitis, renal colic, and inflammatory bowel disease. Toothpick lodged in a colon is forced by peristalsis to make a sharp right turn, resulting in penetration of the mucosa, which can lead to migration to other organs close to the perforating site, thereby demonstrating a very different clinical pathology. [1]
Figure 1: Plastic toothpick emanating from colon after penetrating its wall with inflamed heaped up omentum around it

Click here to view
Figure 2: Inflammed looking omentum freed from site of penetration

Click here to view


Plain radiographic study usually do not identify toothpick unless being radio-opaque. Abdominal ultrasound demonstrates swallowed toothpicks frequently as a hyperechoic, thin, straight line, or a hyperechoic dot. Computed tomography scan of abdomen is used to confirm the locations of both ends of the toothpick, location of perforation, and the extent of intra-abdominal inflammation either with or without abscess formation and in excluding findings requiring surgical intervention. [4] Ingested toothpicks are hyperdense on computed tomography. Colonoscopic removal of toothpicks obviates the need for surgical intervention. Surgical intervention is done where toothpick leads to complications of peritonitis, abscesses, fistulas, migration of toothpicks to adjacent extra-colonic structures, in intractable bleeding, or those having failed endoscopic retrieval. Senile dementia and use of the toothpick could be suggestive of unintentional ingestion of toothpick. Toothpick in gut can be sometimes an intraoperative occult diagnosis, which is unexpected. Delayed manifestations may be attributed to chronic constipation in this case.

 
   References Top

1.Mohanty AK, Flannery MT, Johnson BL, Brady PG. A sharp right turn. N Engl J Med 2006;355:500-5.   Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.McManus JE. Perforation of the intestine by ingested foreign bodies. Am J Surg 1941;53:393-402.  Back to cited text no. 2      
3.Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984;252:796-7.  Back to cited text no. 3  [PUBMED]    
4.Chung YS, Chung YW, Moon SY, Yoon SM, Kim MJ, Kim KO, et al. Toothpick impaction with sigmoid colon pseudodiverticulum formation successfully treated with colonoscopy. World J Gastroenterol 2008;14:948-50.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  

Top
Correspondence Address:
Imtiaz Wani
Department of Surgery, SMHS Hospital, Srinagar, Kashmir
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.70773

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 Toothpick impaction with localized sigmoid perforation: Successful double-balloon enteroscopic management
Wang, Y.-P. and Shi, B.
Endoscopy. 2012; 44(SUPPL. 2)
[Pubmed]
2 Toothpick Perforation of the cecum presenting as right iliac fossa pain: Report of a case and review of literature
Nsour, T. and Al-Gzawi, S. and Al-Soud, N. and Maslamani, A. and Al-Omari, M.
Rawal Medical Journal. 2011; 36(2): 165-166
[Pubmed]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    References
    Article Figures

 Article Access Statistics
    Viewed2600    
    Printed136    
    Emailed0    
    PDF Downloaded20    
    Comments [Add]    
    Cited by others 2    

Recommend this journal