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Toothpick impaction with localized sigmoid perforation: successful colonoscopic management
Toothpick impaction with localized sigmoid perforation: successful colonoscopic management Sanjay K. Reddy, MD, G. Stephen Griffith, MD, Jeffrey A. Goldstein, MD, Neil H. Stollman, MD I f a n i n g e s t e d foreign b o d y s u c c e s s f u l l y n a v i g a t e s t h e e s o p h a g u s , it will f r e q u e n t l y p a s s t h r o u g h t h e e n t i r e G I t r a c t . O p p o s i t i o n to p a s s a g e b e y o n d t h e e s o p h a g u s , however, c a n be d u e to a n a t o m i c condit i o n s or f a c t o r s specific to t h e f o r e i g n body. I m p a c t i o n g e n e r a l l y occurs a t s i t e s of n a r r o w i n g , s u c h as t h e pylorus, t h e l i g a m e n t of Treitz, t h e ileocecal valve, or t h e r e c t o s i g m o i d j u n c t i o n . F u r t h e r m o r e , long, n a r r o w , or p o i n t e d f o r e i g n b o d i e s a r e a s s o c i a t e d w i t h a h i g h e r r i s k of i m p a c t i o n , as well as c o m p l i c a t i o n s s u c h as p e r f o r a t i o n . We r e p o r t a p a t i e n t w i t h a localized p e r f o r a t i o n of t h e s i g m o i d colon, a c o m p l i c a t i o n o f a c c i d e n t a l i n g e s t i o n of a toothpick t h a t was diagnosed and successfully mana g e d colonoscopically.
CASE REPORT A 59-year-old man was referred for colonoscopy to evaluate a complaint, approximately 6 months in duration, of intermittent left lower quadrant discomfort and a finding of fecal occult blood. His past medical history included hypertension and mild depression, with no history of previous surgical procedures. The patient was taking fluoxetine and diltiazem, had a 40 pack-year history of tobacco use, and consumed small amounts of alcohol infrequently. Review of systems was negative for melena, gross blood per rectum, fever, weight loss, or change in bowel habits or stool caliber. The patient's only additional complaint was increased flatus during the last month. Physical examination revealed a moderately obese man, with upper dentures in place. Vital signs were normal, and he was in no evident discomfort. General examination was normal except for the abdomen, which revealed mild discomfort to deep palpation in the left lower quadrant. There were no palpable masses, and no guarding or peritoneal signs. Colonoscopy disclosed sigmoid diverticulosis and a foreign body at approximately the mid-sigmoid level. A toothpick was noted to be lodged in the lumen with surrounding erythema and edema (Fig. 1). One end was impacted within a diverticulum and the other in the wall opposite. From the Division of Gastroenterology, Miami VA Medical Center~Jackson Memorial Medical Center, University of Miami School of Medicine, Miami, Florida. Presented (poster session) at the 63rd Annual Scientific Meeting, American College of Gastroenterology, October 12-14, 1998, Boston, Massachusetts. Reprint requests: Neil H. StoUman, MD, Division of Gastroenterology (D-1007), University of Miami~Miami VA Medical Center, 1201 N W 16th St., Miami, FL 33125. 37/54]100336 708
GASTROINTESTINAL ENDOSCOPY
Figure 1, Endoscopic view of toothpick impacted in wall of sigmoid colon. Gentle probing with a biopsy forceps freed one end, which was then grasped and cautiously removed from the diverticulum. On extraction, purulent fluid flowed immediately from a small divot in the bowel wall. On colonoscopic delivery of the 6.7 • 0.2 cm wooden toothpick per anus, the patient noted a dramatic and immediate decrease in his left lower quadrant discomfort. Subsequent questioning yielded no history of known toothpick ingestion or of meals served with toothpicks, and the patient did not chew on toothpicks. At the conclusion of the procedure, the patient was given one dose of ampicillin]sulbactam. He was advised to continue parenteral antibiotic therapy and remain under observation for 24 to 48 hours; an abdominal CT was ordered. However, the patient left the hospital against medical advice within 5 hours; he was given oral antibiotics on discharge. Four days after leaving the hospital, the patient presented again, this time with complaints of 2 days of watery diarrhea and low-grade fever. He was found to have a temperature of 101~ a normal examination of the abdomen, and a white blood cell count of 19,000/mm 3 (normal value 4800 to 10,000/mm3). CT of the abdomen and pelvis showed sigmoid diverticulosis and significant fluid and fat stranding in the proximal sigmoid flexure, with a localized pneumoperitoneum walled off by omentum (Fig. 2). Treatment with broad spectrum parenteral antibiotics was reinstituted and continued for 7 days. The patient had an uneventful hospital course; the white blood cell count returned to normal within 72 hours. A follow-up CT 4 days later revealed interval improvement. The patient did well after discharge. A follow-up CT 9 weeks later showed complete resolution of the inflammatory process.
DISCUSSION B e t w e e n 80% to 93% of i n g e s t e d objects e n t e r i n g t h e s t o m a c h will be p a s s e d uneventfully.1 P a t i e n t s m a y m a n i f e s t s y m p t o m s d u e to bowel wall p e n e t r a VOLUME 50, NO. 5, 1999
Brief Reports
tion, peritonitis, or an obstructive process. Some m a y present with features mimicking appendicitis or ileitis. 2 A large n u m b e r of reports support the belief t h a t perforation is more common with sharp or pointed objects such as chicken or fish bones, metal objects, and wooden splinters. One 4-year survey found 8176 toothpick-related injuries in the United States, a rate of 3.6/100,000 persons/year. Five percent of these injuries involved i n t e r n a l organs. 3 Toothpick ingestion appears to be commonly implicated in intestinal perforations due to the length and bilateral pointed ends of this foreign body. The consequences of impaction in the GI tract have been commented on since at least 1941, when it was reported t h a t 9% of perforations in one series of ingested foreign bodies were due to wood splinters, toothpicks, or pencils. 4 Historically, toothpick impaction in the lower GI tract has been m a n a g e d by early surgery. As the devices and skills of the endoscopist improve, this approach to m a n a g e m e n t should be reconsidered. One review of a 10-year experience with 101 foreign body ingestions in 100 patients showed t h a t the choice of management among the available options of serial radiographic evaluation, endoscopic retrieval, and operative intervention was based, in part, on whether the foreign body lodged in the esophagus, passed easily to the stomach, or was suspected of causing "impending" perforation. 5 Admittedly, impending perforation was diagnosed with difficulty in most cases. Half of the patients undergoing surgery (or 6% of the total in the study) were asymptomatic at the time and some, in retrospect, might have been candidates for nonsurgical management. With little data on colonoscopic retrieval in such cases, it is difficult to establish definitive guidelines. Obviously, operative removal of a frankly perforating toothpick is prudent, but it appears that in some cases endoscopic intervention m a y be accomplished at acceptable rates of morbidity and mortality. Several case reports describe endoscopic removal of toothpicks from the duodenum, appendix, transverse colon, and rectum.6-9 Rex and Bilotta 1~ described 2 patients with chicken bones impacted in the sigmoid colon, w i t h o u t peritoneal signs, who were successfully m a n a g e d colonoscopically. Another report of successful endoscopic diagnosis and t r e a t m e n t of a chicken bone ingestion by Tarnasky et a1.11 illustrates several factors strongly associated w i t h foreign body inges-
VOLUME 50, NO. 5, 1999
S Reddy, S Griffith, J Goldstein, et al.
Figure 2, Pelvic CT showing perisigmoid inflammation, fat stranding, and localized pneumoperitoneum (arrow). tions. These included impaired palatal and gingival sensation, previous gastric surgery, and colonic diverticulosis.
REFERENCES 1. HendersonCT,Engel J, SchlesingerP. Foreignbodyingestion: review and suggested guidelinesfor management.Endoscopy 1987;19:68-71. 2. Guber MD, Suarez CA, Greve J. Toothpickperforation of the intestine diagnosed by a small bowel series. Am J Gastroenterol 1996;91:789-91. 3. BudnickLD. Toothpick-relatedinjuries in the United States, 1979 through 1982. JAMA 1984;252:796-7. 4. McManusJE. Perforationof the intestine by ingested foreign bodies. Am J Surg 1941;53:393-402. 5. SelivanovV, Sheldon GF, CelloJP, Crass RA. Managementof foreign body ingestion.Ann Surg 1984;199:187-91. 6. Tenner S, Wong RC, Carr-Locke D, Davis SK, Farraye FA. Toothpick ingestion as a cause of acute and chronic duodenal inflammation.Am J Gastroenterol 1996;91:1860-2. 7. Meltzer SJ, GoldbergMD, Meltzer RM, Claps F. Appendiceal obstruction by a toothpick removed at colonoscopy.Am J Gastroenterol 1986;81:1107-8. 8. MonkemullerKE, Patil R, Marino CR. Endoscopicremoval of a toothpick from the transverse colon. Am J Gastroenterol 1996;91:2438-9. 9. Callon RA, Brady PG. Toothpick perforation of the sigmoid colon: an unusual case associated with Erysipelothrix rhusiopathiae septicemia. Gastrointest Endosc 1990;36:141-3. 10. Rex DK, Bilotta J. Colonoscopicremoval of chicken bones impacted in the sigmoidin two patients. Gastrointest Endosc 1997;46:193-5. 11. Tarnasky PR, NewcomerMK, Branch MS. Colonoscopicdiagnosis and treatment of chronicchickenbone perforationofthe sigmoid colon. Gastrointest Endosc 1994;40:373-5.
GASTROINTESTINAL ENDOSCOPY 709
CASE REPORT A 59-year-old man was referred for colonoscopy to evaluate a complaint, approximately 6 months in duration, of intermittent left lower quadrant discomfort and a finding of fecal occult blood. His past medical history included hypertension and mild depression, with no history of previous surgical procedures. The patient was taking fluoxetine and diltiazem, had a 40 pack-year history of tobacco use, and consumed small amounts of alcohol infrequently. Review of systems was negative for melena, gross blood per rectum, fever, weight loss, or change in bowel habits or stool caliber. The patient's only additional complaint was increased flatus during the last month. Physical examination revealed a moderately obese man, with upper dentures in place. Vital signs were normal, and he was in no evident discomfort. General examination was normal except for the abdomen, which revealed mild discomfort to deep palpation in the left lower quadrant. There were no palpable masses, and no guarding or peritoneal signs. Colonoscopy disclosed sigmoid diverticulosis and a foreign body at approximately the mid-sigmoid level. A toothpick was noted to be lodged in the lumen with surrounding erythema and edema (Fig. 1). One end was impacted within a diverticulum and the other in the wall opposite. From the Division of Gastroenterology, Miami VA Medical Center~Jackson Memorial Medical Center, University of Miami School of Medicine, Miami, Florida. Presented (poster session) at the 63rd Annual Scientific Meeting, American College of Gastroenterology, October 12-14, 1998, Boston, Massachusetts. Reprint requests: Neil H. StoUman, MD, Division of Gastroenterology (D-1007), University of Miami~Miami VA Medical Center, 1201 N W 16th St., Miami, FL 33125. 37/54]100336 708
GASTROINTESTINAL ENDOSCOPY
Figure 1, Endoscopic view of toothpick impacted in wall of sigmoid colon. Gentle probing with a biopsy forceps freed one end, which was then grasped and cautiously removed from the diverticulum. On extraction, purulent fluid flowed immediately from a small divot in the bowel wall. On colonoscopic delivery of the 6.7 • 0.2 cm wooden toothpick per anus, the patient noted a dramatic and immediate decrease in his left lower quadrant discomfort. Subsequent questioning yielded no history of known toothpick ingestion or of meals served with toothpicks, and the patient did not chew on toothpicks. At the conclusion of the procedure, the patient was given one dose of ampicillin]sulbactam. He was advised to continue parenteral antibiotic therapy and remain under observation for 24 to 48 hours; an abdominal CT was ordered. However, the patient left the hospital against medical advice within 5 hours; he was given oral antibiotics on discharge. Four days after leaving the hospital, the patient presented again, this time with complaints of 2 days of watery diarrhea and low-grade fever. He was found to have a temperature of 101~ a normal examination of the abdomen, and a white blood cell count of 19,000/mm 3 (normal value 4800 to 10,000/mm3). CT of the abdomen and pelvis showed sigmoid diverticulosis and significant fluid and fat stranding in the proximal sigmoid flexure, with a localized pneumoperitoneum walled off by omentum (Fig. 2). Treatment with broad spectrum parenteral antibiotics was reinstituted and continued for 7 days. The patient had an uneventful hospital course; the white blood cell count returned to normal within 72 hours. A follow-up CT 4 days later revealed interval improvement. The patient did well after discharge. A follow-up CT 9 weeks later showed complete resolution of the inflammatory process.
DISCUSSION B e t w e e n 80% to 93% of i n g e s t e d objects e n t e r i n g t h e s t o m a c h will be p a s s e d uneventfully.1 P a t i e n t s m a y m a n i f e s t s y m p t o m s d u e to bowel wall p e n e t r a VOLUME 50, NO. 5, 1999
Brief Reports
tion, peritonitis, or an obstructive process. Some m a y present with features mimicking appendicitis or ileitis. 2 A large n u m b e r of reports support the belief t h a t perforation is more common with sharp or pointed objects such as chicken or fish bones, metal objects, and wooden splinters. One 4-year survey found 8176 toothpick-related injuries in the United States, a rate of 3.6/100,000 persons/year. Five percent of these injuries involved i n t e r n a l organs. 3 Toothpick ingestion appears to be commonly implicated in intestinal perforations due to the length and bilateral pointed ends of this foreign body. The consequences of impaction in the GI tract have been commented on since at least 1941, when it was reported t h a t 9% of perforations in one series of ingested foreign bodies were due to wood splinters, toothpicks, or pencils. 4 Historically, toothpick impaction in the lower GI tract has been m a n a g e d by early surgery. As the devices and skills of the endoscopist improve, this approach to m a n a g e m e n t should be reconsidered. One review of a 10-year experience with 101 foreign body ingestions in 100 patients showed t h a t the choice of management among the available options of serial radiographic evaluation, endoscopic retrieval, and operative intervention was based, in part, on whether the foreign body lodged in the esophagus, passed easily to the stomach, or was suspected of causing "impending" perforation. 5 Admittedly, impending perforation was diagnosed with difficulty in most cases. Half of the patients undergoing surgery (or 6% of the total in the study) were asymptomatic at the time and some, in retrospect, might have been candidates for nonsurgical management. With little data on colonoscopic retrieval in such cases, it is difficult to establish definitive guidelines. Obviously, operative removal of a frankly perforating toothpick is prudent, but it appears that in some cases endoscopic intervention m a y be accomplished at acceptable rates of morbidity and mortality. Several case reports describe endoscopic removal of toothpicks from the duodenum, appendix, transverse colon, and rectum.6-9 Rex and Bilotta 1~ described 2 patients with chicken bones impacted in the sigmoid colon, w i t h o u t peritoneal signs, who were successfully m a n a g e d colonoscopically. Another report of successful endoscopic diagnosis and t r e a t m e n t of a chicken bone ingestion by Tarnasky et a1.11 illustrates several factors strongly associated w i t h foreign body inges-
VOLUME 50, NO. 5, 1999
S Reddy, S Griffith, J Goldstein, et al.
Figure 2, Pelvic CT showing perisigmoid inflammation, fat stranding, and localized pneumoperitoneum (arrow). tions. These included impaired palatal and gingival sensation, previous gastric surgery, and colonic diverticulosis.
REFERENCES 1. HendersonCT,Engel J, SchlesingerP. Foreignbodyingestion: review and suggested guidelinesfor management.Endoscopy 1987;19:68-71. 2. Guber MD, Suarez CA, Greve J. Toothpickperforation of the intestine diagnosed by a small bowel series. Am J Gastroenterol 1996;91:789-91. 3. BudnickLD. Toothpick-relatedinjuries in the United States, 1979 through 1982. JAMA 1984;252:796-7. 4. McManusJE. Perforationof the intestine by ingested foreign bodies. Am J Surg 1941;53:393-402. 5. SelivanovV, Sheldon GF, CelloJP, Crass RA. Managementof foreign body ingestion.Ann Surg 1984;199:187-91. 6. Tenner S, Wong RC, Carr-Locke D, Davis SK, Farraye FA. Toothpick ingestion as a cause of acute and chronic duodenal inflammation.Am J Gastroenterol 1996;91:1860-2. 7. Meltzer SJ, GoldbergMD, Meltzer RM, Claps F. Appendiceal obstruction by a toothpick removed at colonoscopy.Am J Gastroenterol 1986;81:1107-8. 8. MonkemullerKE, Patil R, Marino CR. Endoscopicremoval of a toothpick from the transverse colon. Am J Gastroenterol 1996;91:2438-9. 9. Callon RA, Brady PG. Toothpick perforation of the sigmoid colon: an unusual case associated with Erysipelothrix rhusiopathiae septicemia. Gastrointest Endosc 1990;36:141-3. 10. Rex DK, Bilotta J. Colonoscopicremoval of chicken bones impacted in the sigmoidin two patients. Gastrointest Endosc 1997;46:193-5. 11. Tarnasky PR, NewcomerMK, Branch MS. Colonoscopicdiagnosis and treatment of chronicchickenbone perforationofthe sigmoid colon. Gastrointest Endosc 1994;40:373-5.
GASTROINTESTINAL ENDOSCOPY 709