Electronic Clinical Challenges and Images in GI
Article Outline
- Image 4
- Answer to the Clinical Challenges and Images in GI Question: Image 4 Perforating Toothpick Mimicking Crohn's Disease of the Ileum
- References
- Copyright
Image 4
Question: A 42-year-old man presented to the emergency unit with a 10-day history of abdominal cramps, more severe in the lower quadrants, and associated with watery-loose stools. He had nausea and 1 episode of nonbloody emesis. The symptoms started while he was on vacation where he was treated with analgesics plus empiric antibiotics without improvement. He denied fever, chills, melena, or hematochezia. No similar episodes were reported.
His past history was significant for bilateral inguinal hernia repair, gouty arthritis treated with allopurinol, and recurrent subcutaneous abscesses with cultured methicillin-resistant Staphylococcus aureus.
On presentation, his vital signs and physical examination were normal except for severe tenderness in the right lower abdominal quadrant. Laboratory examinations showed Entamoeba histolytica cysts, 2–3/hpf; white blood cells, many/hpf; red blood cells, 10–15/hpf on stool examination; and normal CBC and liver function tests. Abdominal computed tomography (CT) (Figure A) showed thickening of the wall of most of the ileum, more to be in the distal part with some stranding of the mesentery in the right lower quadrant, most likely from Crohn's disease.
Colonoscopy revealed few cecal diverticula with normal-appearing cecal and terminal ileal mucosa. The scope was further advanced into the distal ileum about 20 cm from the ileocecal valve, where a yellowish lesion with severe mucosal erythema, edema, and purulent discharge was observed (Figure B). What is the diagnosis?
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Answer to the Clinical Challenges and Images in GI Question: Image 4 Perforating Toothpick Mimicking Crohn's Disease of the Ileum
The object was an impacted, perforating, 6-cm, double-pointed toothpick that was ingested without the patient's awareness. One end of the toothpick was dislodged using cautious inflation, grasped with biopsy forceps, and pulled out (Figure B).
Most ingested foreign bodies pass through the gastrointestinal tract spontaneously. The shape, size, and kind of foreign bodies are of great importance for the diagnosis and anticipation of possible complications. Sharp-pointed objects predispose patients to a greater risk of complications, which may reach up to 35%.1 Narrowed areas of the lumen are the most common places for impaction, perforation, or obstruction. Narrowing can be physiologic, congenital, or iatrogenic.
Ingested foreign objects such as fish or chicken bones, wood, plastic, most glass, and thin metal objects are not easily identified on radiologic investigations.1 Surprisingly, most of the patients swallowing toothpicks do not recall this event, which makes the diagnosis challenging.2 Impacted or perforating foreign body should be in the differential diagnosis in abdominal pain presentations of unclear etiology and endoscopy is the major diagnostic and therapeutic tool. This is a unique case of successful endoscopic removal of a perforating toothpick from the ileum. After removal of the toothpick, the patient's condition improved significantly and was discharged on metronidazole and ciprofloxacin for 1 week.
References
Conflicts of interest The authors disclose no conflicts.
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PII: S0016-5085(08)01897-0
doi:10.1053/j.gastro.2008.10.059
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
