Correspondence

Subphrenic Abscess Related to the Ingestion of a Toothpick

N Engl J Med 1998; 338:133-135January 8, 1998

Article

To the Editor:

The development of intraabdominal abscesses secondary to the ingestion of foreign bodies is a known but infrequent phenomenon.1 We describe a patient with a right subphrenic abscess that developed after the accidental ingestion of a toothpick 15 months earlier. Images obtained through abdominal ultrasonography were helpful in making a preoperative diagnosis.

A 52-year-old man was referred to the hospital because of progressive weight loss of 10 kg during the preceding six months, despite the presence of a good appetite. There was no history of fever, chills, vomiting, or abdominal pain. There was a history of non-insulin-dependent diabetes mellitus, and he had smoked one pack of cigarettes per day for many years. On physical examination he was thin. The blood chemical values and hematologic profile were normal, except that the glucose level was 162 mg per deciliter (8.99 mmol per liter) and the alkaline phosphatase level was elevated (354 U per liter; normal, <270). Upper gastrointestinal endoscopy revealed no abnormalities. Abdominal ultrasonography demonstrated a complex, predominantly hypoechoic mass that seemed to be within the left lobe of the liver and measured 7 cm in diameter. Next to and partially within this lesion was a hyperechoic linear image measuring 6 cm, possibly representing a foreign body, apparently a toothpick (Figure 1Figure 1Abdominal Ultrasonographic Image Showing the Liver (L), the Abscess (A), and the Toothpick (Arrow).). Contrast-enhanced abdominal computed tomography confirmed the presence of the mass.

At surgery the mass was found to be a subphrenic abscess that contained a toothpick. The abscess was drained, and the patient was treated for 10 days with antibiotics. The culture of the abscess grew Escherichia coli. When questioned, the patient remembered that 15 months earlier he had accidentally swallowed a toothpick but had paid no attention to it since he had had no symptoms. Twelve days after surgery, he was discharged from the hospital completely asymptomatic.

Intraabdominal abscesses secondary to perforation of the gastrointestinal tract by ingested foreign bodies are not rare. In most cases these objects are sharp and are swallowed accidentally, sometimes long before they cause symptoms, and frequently, patients do not remember ingesting them.2 Liver abscesses related to the ingestion of toothpicks have been reported.3,4 The image of the toothpick provided by ultrasonography in this case was very helpful in making the diagnosis.

José L. Zambrana, M.D., Ph.D.
Juan A. García-Gutiérrez, M.D.
Felipe Díez, M.D., Ph.D.
Hospital de Poniente, 04700 El Ejido (Almería), Spain

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Citing Articles (6)

Citing Articles

1. 1

   Felix Gundling, Wolfgang Schepp, Martin Fuchs. (2011) Abdominal Pain After Consumption of a Bavarian Beef Roulade in a 45-Year-Old Patient. Gastroenterology 141:3, 810-1127
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2. 2

   Masanori Fukushima, Masaki Yamakawa, Kouki Ikeda, Norihiro Kohara, Ken Ohnita, Hajime Isomoto, Fuminao Takeshima, Kazuhiko Nakao. (2011) A Case of Penetration of the Colon by a Toothpick Successfully Removed during Colonoscopy. Nippon Daicho Komonbyo Gakkai Zasshi 64:5, 343-348
   CrossRef

3. 3

   Yutaka ABE, Tadashi IIJIMA, Aya NISHIMURA, Motohiko FUKUSHIMA. (2008) A CASE OF SMALL INTESTINAL PERFORATION BY A CHICKEN BONE. Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association) 69:11, 2897-2899
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4. 4

   Takahiro Imai, Tomoko Kitagawa, Toshiya Nishibe, Masayasu Nishibe. (2007) A Rectum Perforation Due to Toothpick Accidentally Swallowed by Patient Who Presented with Scrotal Subcutaneous Abscess. Nihon Kyukyu Igakukai Zasshi 18:5, 196-201
   CrossRef

5. 5

   A Olsen. (1998) Regulatory Action Criteria for Filth and Other Extraneous Materials I. Review of Hard or Sharp Foreign Objects as Physical Hazards in Food. Regulatory Toxicology and Pharmacology 28:3, 181-189
   CrossRef

6. 6

   (1998) The Health Care Costs of Smoking. New England Journal of Medicine 338:7, 470-472
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