Successful endoscopic retrieval of a toothpick stuck in the small intestine using double-balloon enteroscopy

A 59-year-old man was admitted to our hospital with nausea and vomiting. Laboratory test results demonstrated an elevated white blood cell count of 10 540/µL (normal range 3200 – 8000/µL) and his C-reactive protein (CRP) level was 2.82 mg/dL (normal < 0.30 mg/dL). He had a history of appendectomy for appendicitis and ventriculoperitoneal shunting for subarachnoid hemorrhage. Abdominal computed tomography (CT) showed a small-bowel obstruction (SBO) with dilatation, fluid collection, and caliber change in the proximal part of the small intestine ([Fig. 1 a]). Ascites, abscesses, and free air were not observed; however, a high-density needle-shaped structure was noted incidentally inside the proximal part of the small intestine with minimal surrounding inflammation ([Fig. 1 b]).

Fig. 1 Abdominopelvic computed tomography scan showing the distended and fluid-filled small bowel (S) and caliber change (arrow) in the proximal part of the small intestine, which is consistent with small bowel obstruction, on: a axial view; b reconstructed sagittal image, which also shows a high-density needle-shaped structure inside the small intestine (arrowhead).

A transnasal ileal tube was placed to decompress the SBO; after 4 days, the SBO had improved, so the tube was removed. In order to remove the foreign body from the small intestine, we performed double-balloon enteroscopy (DBE) via the oral route ([Fig. 2 a]). DBE revealed a wooden toothpick that was stuck in the proximal part of the small intestine ([Fig. 2 b]), and we successfully removed the toothpick using grasping forceps without any complications ([Fig. 3]; [Video 1]). A follow-up CT scan immediately after the DBE revealed no free air surrounding the small intestine.

Fig. 2 Double-balloon enteroscopy (DBE) via the oral route showing: a on radiographic imaging, the position of the stuck toothpick in the small intestine (arrow); b on endoscopic view, the ingested toothpick stuck in the small intestine wall.

Fig. 3 Photograph of the removed 6.5-cm toothpick (arrow). For comparison, an unused toothpick (arrowhead) is also shown.

Video 1 Endoscopic retrieval of a toothpick stuck in the small intestine using double-balloon enteroscopy via the oral route and grasping forceps.

The patient had no memory of ingesting the toothpick. His clinical course was uneventful, and he was discharged 9 days after the DBE.

According to previous reports, toothpick perforation of the duodenum can be treated with endoscopic removal [1] [2] [3]. However, toothpick perforation of the small intestine, which often exists with other complications, such as abscess formation, has previously been treated by laparotomy [4] [5]. To the best of our knowledge, this is the first English case report of the successful endoscopic removal of a toothpick stuck in the small intestine using DBE. We suggest that DBE may offer a nonsurgical alternative for the removal of a toothpick stuck in the small intestine.

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• References

• 1 Robert B, Bartoli E, Fumery M. et al. Duodenal perforation due to toothpick perforation, an uncommon cause of chronic abdominal pain. Endoscopy 2012; 44: E27-E28
• 2 Hsieh MJ, Lee TC, Tseng CH. et al. Duodenum-penetrating toothpick with liver abscess: removal with single-balloon enteroscopy. Endoscopy 2011; 43: E11-E12
• 3 Wu SS, Yen HH, Chen YY. et al. Successful endoscopic retrieval of an impacted toothpick in the duodenum (with video). Gastrointest Endosc 2006; 63: 329 discussion 329
• 4 Lai CMS, Lui TH. Small bowel perforation by toothpick. BMJ Case Rep 2018; DOI: 10.1136/bcr-2018-225258.
• 5 Mark D, Ferris K, Martel G. et al. Radiological diagnosis of a small bowel perforation secondary to toothpick ingestion. BMJ Case Rep 2013; DOI: 10.1136/bcr-2013-009869.