Correspondence

Is Your Food Free of Wood?

N Engl J Med 2000; 343:1817-1818December 14, 2000

Article

To the Editor:

Foreign bodies are often ingested accidentally — for example, by people with dentures or those with mental impairment.1 Usually, the material passes through the gastrointestinal tract uneventfully.2 We describe a man with abdominal pain that was caused by a toothpick encapsulated in an abscess in the right psoas muscle.

A 69-year-old man presented with a three-month history of right-sided abdominal pain. He had no fever, nausea, vomiting, or diarrhea. The white-cell count was 11,000 per cubic millimeter, the C-reactive protein level was 2.9 mg per deciliter (normal, <0.5), and there were red cells in the urine. Abdominal ultrasonography, chest and abdominal radiography, gastroduodenoscopy, and whole-body scintigraphy revealed no abnormalities.

Ten days after admission, a right psoas abscess was tentatively identified by ultrasonography and confirmed by computed tomography. Subsequently, purulent fluid was evacuated from the abscess and cultured. Cultures were positive for Escherichia coli and enterococci. A Löwenstein culture for mycoplasma was negative, as were the results of Ziehl–Neelsen staining.

Because of recurring symptoms, the patient underwent surgery. The surgeon removed a wooden toothpick (length, 5.8 cm) that was impacted within the abscess wall. Adjacent structures were intact. There was scar tissue between the abscess wall and the inferior portion of the duodenum, which may have reflected the path of the toothpick. The patient had an uneventful recovery.

Complications associated with the ingestion of a foreign body include impaction, obstruction, perforation, penetration, and fistulation.2 Perforation occurs in less than 1 percent of cases.2 Toothpicks have been reported to have perforated the sigmoid colon,1,3 the cecum,4 the stomach,1 and the small intestine.1,4,5

Intraperitoneal perforation is accompanied by acute pain and peritoneal irritation, whereas perforation of the retroperitoneum initially causes fewer symptoms.4 This factor may delay diagnosis and account for the high mortality associated with retroperitoneal perforations.4 It is difficult to identify and thus diagnose nonradiopaque foreign bodies. In our patient, the toothpick was not identified by ultrasonography, computed tomography, or gastroduodenoscopy, not even retrospectively.

Johannes Zacherl, M.D.
University of Vienna, A-1090 Vienna, Austria

Heinrich Zacherl, M.D.
Lukas Koppensteiner, M.D.
Public Hospital Hainburg, A-2410 Hainburg, Austria

5 References

1. 1

   Rioux M, Langis P. Sonographic detection of clinically unsuspected swallowed toothpicks and their gastrointestinal complications. J Clin Ultrasound 1994;22:483-490
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2. 2

   Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases. World J Surg 1996;20:1001-1005
   CrossRef | Web of Science | Medline

3. 3

   Kaufman E, Sommers E. Sigmoid colon perforation: result of accidental swallowing of a toothpick. Oral Surg Oral Med Oral Pathol 1984;58:535-536
   CrossRef | Medline

4. 4

   Hauser H, Pfeifer J, Uranus S, Klimpfinger M. Perforation of the cecum by a toothpick: case report and review of the literature. Langenbecks Arch Chir 1994;379:229-232
   CrossRef | Medline

5. 5

   Guber MD, Suarez CA, Greve J. Toothpick perforation of the intestine diagnosed by a small bowel series. Am J Gastroenterol 1996;91:789-791
   Web of Science | Medline