A 2014 review collected 136 case reports of accidental toothpick ingestion over an 85 year period. While swallowing a toothpick is a rare, the damage is often significant because the long narrow pointy object does not easily pass through the G.I. tract.

Just over half the patients did not remember swallowing a toothpick. Of those who recalled the event, about one-third had eaten sandwiches held together by toothpicks. Most toothpicks lodged in the small intestine and colon.

Although endoscopy successfully removed toothpicks from the stomach, duodenum/small bowel, colon, and rectum in one-third of cases, laparotomy or laparoscopy was required in the rest. Toothpick migration out of the G.I. tract creates special problems. Here are some examples.

A 45-year-old woman was admitted with sepsis and multiorgan failure. A CT scan showed a liver abscess, which resolved with antibiotic therapy. She was electively explored months later. Intraoperative ultrasound showed what turned out to be a toothpick embedded in the left lobe of the liver. [Figure 1. Toothpick below arrow.] The lateral liver segment containing the toothpick was resected, and she did well.

A similar case is depicted in Figures 2 and 3. The toothpick is below the arrows:

Small black arrow is pointing to bubbles in the IVC.

A 57-year-old man presented with lower abdominal pain. An ultrasound was negative. The pain increased, inflammatory markers rose, and a CT scan showed a thrombus containing air bubbles in the inferior vena cava (IVC) and a toothpick entering the IVC from the small bowel. [Figure 4.] The toothpick was removed via an enterotomy and the clot was successfully treated with antibiotics and thrombolysis.

A 49-year-old man with upper abdominal pain underwent gastroscopy, which showed a toothpick embedded in the duodenum. He was transferred to a second hospital where hematuria was also noted. Small black arrow is pointing to bubbles in the IVC.A CT scan showed an object penetrating the duodenal wall into the right kidney. [Figure 5.] It could not be located by repeat endoscopy. Laparotomy and duodenostomy were performed, and the toothpick was removed. He recovered.

A 42-year-old man was febrile with shortness of breath, hemoptysis, and positive blood cultures for Pseudomonas. An initial CT scan was non-diagnostic. An echocardiogram showed a small mass in the right ventricle which resolved with antibiotics. Four months later, he was febrile with another positive blood culture, and repeat echo showed a linear density in the same area as before. [Figure 6.] He underwent surgery and a 6.5 cm toothpick was located and removed. It grew Pseudomonas. The patient recovered.

A 55-year-old woman was found dead at home. She had a greenish area in her anterior neck. [Figure 7.] At autopsy, a 3.5 cm toothpick fragment had penetrated the upper esophagus, and a culture grew Klebsiella. She had been seen in an emergency department twice in the 5 days before her death for throat discomfort after eating salami with bread. Laryngoscopy and plain x-rays were negative. Despite the history and elevated inflammatory markers, she was cleared by a psychiatrist, treated for an upper respiratory infection, and discharged.

These cases, particularly the last one, illustrate the elusive nature of swallowed toothpick injuries.

 

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times.For the last 9 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.