Toothpick injury mimicking renal colic: case report and systematic review

The Journal of Emergency Medicine, Vol. 23, No. 1, pp. 35–38, 2002 Copyright © 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/02 $–see front matter

PII S0736-4679(02)00458-4

Clinical Communications

TOOTHPICK INJURY MIMICKING RENAL COLIC: CASE REPORT AND SYSTEMATIC REVIEW Siu Fai Li,

MD,

and Kimberly Ender,

MD

Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, Reprint Address: Siu Fai Li, MD, Department of Emergency Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY 10461

e Abstract—We describe a case of a patient with left flank pain that was caused by a perforation in the splenic flexure of the colon by a toothpick. We conducted a systematic review of the literature to examine the nature of injuries caused by ingested toothpicks. Articles were analyzed for the following outcome variables: presenting complaint, site of injury, recollection of toothpick ingestion, time to presentation, findings from imaging studies, and mortality. Most patients (70%) presented with abdominal pain. Few patients (12%) remember swallowing a toothpick. The onset of symptoms ranged from <1 day to 15 years. Toothpicks caused perforation most frequently at the duodenum and the sigmoid. In some cases, toothpicks migrated outside the gastrointestinal tract and were found in the pleura, pericardium, ureter, or bladder. Toothpicks were apparent on imaging studies in 14% of the cases. The definitive diagnosis was most commonly made at laparotomy (53%), followed by endoscopy (19%). Overall mortality was 18%. Ingested toothpicks may cause significant gastrointestinal injuries, and must be treated with caution. © 2002 Elsevier Science Inc.

colic. We conducted a systematic review of the literature of injuries from ingested toothpicks. CASE REPORT A 25-year-old man presented to the Emergency Department (ED) with left flank pain. The pain began acutely at rest 1 h before arrival. It was sharp in character and moderately severe in intensity. The pain began in the left flank and radiated to the left groin. He felt nausea with the pain, but there was no vomiting or diarrhea. There was no report of dysuria, hematuria, or frequency of urination. He was well before this attack, and he had never had this pain before. He reported no medical problems, no surgical history, took no medications, denied illicit drug use, and there was no family history of kidney disease. Physical examination revealed a young man in pain. The vital signs were: blood pressure 128/74 torr, heart rate 90 beats/min, respiratory rate 16 breaths/min, and temperature 38.2°C (100.7°F). The physical examination was normal. Bowel sounds were present without distention or abdominal tenderness. There was no costovertebral angle tenderness. Laboratory studies (CBC, chemistries, urinalysis, type and screen) were obtained. An urinalysis conducted in the ED was normal. The presumptive diagnosis was left nephrolithiasis despite the normal urinalysis. The patient was given IV normal saline and ketoralac 30 mg IV with

e Keywords—toothpick; renal colic; abdominal pain; endoscopy; ultrasound; CT scan

INTRODUCTION Toothpicks are relatively sharp instruments that can cause bowel perforation when they are swallowed accidentally. We describe a case of toothpick perforation of the large bowel that mimicked the presentation of renal

RECEIVED: 2 July 2001; FINAL ACCEPTED: 28 January 2002

SUBMISSION RECEIVED:

28 December 2001; 35

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S. F. Li and K. Ender

resolution of the pain. It was uncertain that the patient had renal colic, and a noncontrast computed tomography (CT) scan of the abdomen using a renal protocol was ordered to confirm the diagnosis. The CT scan was performed 2 h after admission to the ED. The results were normal, without evidence of nephrolithiasis or abdominal pathology. After the patient returned from the CT scan, his pain returned. The patient’s abdomen became tender to palpation, particularly in the left upper quadrant and left flank area. There was guarding but no rebound tenderness. The laboratory tests were normal except for a white blood cell (WBC) count of 14; the differential was normal. The surgery service was consulted with the plan to admit the patient to the hospital. The patient underwent another CT scan of the abdomen, this time with contrast, because of the concerning examination. The second CT scan demonstrated pneumoperitoneum and inflammatory changes near the splenic flexure of the colon. The patient was taken to the operating room (OR) for an exploratory laparotomy, where a toothpick was found to have perforated the splenic flexure. There was minimal peritoneal contamination of colonic content. The toothpick was removed and the patient underwent a segmental resection of the colon with primary reanastomosis. The patient had an unremarkable recovery after 5 days of antibiotics and was discharged from the hospital after 1 week. In retrospect, the patient did not recall swallowing the toothpick.

DISCUSSION We conducted a systematic review of the literature to examine the nature of injuries caused by ingested toothpicks. We searched Medline using the textword “toothpick” and examined articles from 1966 to 2000, limiting the search to those in English and human subjects. The citations were reviewed to identify those associated with injuries from ingested toothpicks. Articles were analyzed for the following variables: presenting complaint, site of injury, recollection of toothpick ingestion, time to presentation, duration of the symptomatic period, the presence of fever or shock, findings from imaging studies, endoscopy, operations, mortality, and identifiable risk factors (denture usage, alcoholism, habit of chewing on toothpicks). A temperature of 38.1°C (100.6°F) or higher was considered as fever. A systolic blood pressure of 90 mm Hg or less was considered to be hypotension. One hundred and twelve articles were identified, of which 47 met entry criteria (1– 47). The articles comprised case reports including 57 patients. The average age of the patients was 52 years (range 7 to 82). Two of the injuries were reported in children. The vast majority of the patients were men (88%). Most patients (70%)

Table 1. Sites of Injury from Toothpicks Duodenum Sigmoid Ileum Jejunum Cecum Asc./Trans./Desc. Colon Rectum Stomach Other

25% 14% 9% 7% 7% 7% 7% 4% 17%

presented with abdominal pain, while 7% of patients presented with gastrointestinal (GI) bleeding. Temperature was recorded in 43 patients, 54% of whom presented with fever. Of the 49 patients in whom blood pressure was reported, 20% presented with hypotension. Only 12% of patients remembered swallowing a toothpick, but many more patients (21%) recalled eating something with a toothpick without swallowing the toothpick. In patients who remember swallowing a toothpick, the onset of symptoms ranged from ⬍1 day to 15 years. The duration of symptoms before diagnosis ranged from 1 day to 9 months. Only about half of the patients (46%) had a reported risk factor for toothpick ingestion. Male sex was the variable most strongly associated with toothpick injuries. All but one of the toothpicks was made of wood. Toothpicks caused injury most frequently at the duodenum, followed by the sigmoid (Table 1). In 7 cases, toothpicks migrated outside the GI tract and were found in the pleura, pericardium, peritoneum, ureter, or bladder (3,11,22,24,31,37,38). In 5 cases, the toothpick caused a fistula with a major blood vessel, such as the aorta or inferior vena cava (2,24,30,33,35). Two of the five patients presented with GI bleeding. Toothpicks were apparent on imaging studies in 14% of the cases (Table 2). The definitive diagnosis was most commonly made at laparotomy (53%), followed by endoscopy (19%), imaging studies (14%), and autopsy (12%). Overall mortality was 18%. The mortality of patients presenting in shock or with enteric-vascular fistulas was extremely high (70% and 80%, respectively). There are several limitations to our review. First, there is selection bias in our study population. Cases that are reported in the literature are likely to have more unusual presentations and more complications. Second, most patients did not remember having swallowed a toothpick. Consequently, we do not know the true rate of complications caused by toothpick ingestions; many cases may be completely asymptomatic. Finally, many of the imaging modalities (e.g., CT, US, endoscopy) were not available at the time of the earlier reported cases. Thus, comparisons between patients may not be valid.

Toothpick Injury Mimicking Renal Colic

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Table 2. Sensitivity of Imaging Studies in Detecting Toothpicks

X-ray CT US Endoscopy

N

Positive

Sensitivity

32 20 14 20

3 3 4 14

9% 15% 29% 70%

CT ⫽ computed tomography scan; US ⫽ ultrasound.

CONCLUSIONS Although toothpicks may be viewed as relatively benign objects, the present case and the review of the literature clearly demonstrate that toothpicks may cause severe, sometimes fatal, internal injuries. Swallowed toothpicks should be treated as foreign body ingestions that have a high potential for causing gastrointestinal perforation. Reliable, asymptomatic patients can be given detailed instructions and followed as outpatients. Symptomatic patients should be admitted for observation for signs of gastrointestinal perforation. Imaging studies are inadequate in detecting ingested toothpicks, and thus, we must continue to rely on the physical examination as the best indicator of injury, as was the case in our patient.

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