A novel clip-assisted method for endoscopic removal of an impacted toothpick from the colon

Perforated acute abdomen is a common syndrome among nontraumatic abdominal emergencies [1]. Bowel perforations may occur because of inflammatory, neoplastic, traumatic, or infectious processes in the digestive tract [2]. They can also be due to ingestion of foreign bodies or as a result of diagnostic and therapeutic medical procedures [2]. The bowel perforation can present as diffuse peritonitis, when it occurs in free peritoneum, or as an obstructive process [3].

Bowel perforation is unusual after foreign body ingestion. However, it can occur when the object is long and pointed, in areas of physiological or pathological narrowing [4]. We describe a case of bowel perforation in the sigmoid colon that was caused by a foreign body, namely a toothpick, and treated endoscopically.

A 14-year-old boy presented with abdominal pain in the right iliac fossa and hypogastrium, nausea, and headache. He was feverish and had experienced an episode of diarrhea. Laboratory tests showed leukocytosis and elevation of C-reactive protein. Inconclusive radiological evaluation with abdominal ultrasound showed inflammatory changes of mesenteric fat in the right iliac fossa and hypogastrium. Abdominal computed tomography showed a thickening of the wall of the sigmoid colon, about 23 cm from the anal margin, fat stranding, and an extraluminal air bubble. The cecal appendix was unchanged. Completion of the examination using rectal contrast showed an image suggestive of a foreign body causing perforation of the colon ([Fig. 1]).

Fig. 1 A 14-year-old boy presented with pain in the right iliac fossa and hypogastrium, nausea, headache, and fever, and had experienced an episode of diarrhea. Abdominal computed tomography (CT) showed a foreign body in the sigmoid, associated with fat stranding and presence of pneumoperitoneum.

An endoscopic examination was done, with bowel preparation using only 1000 mL of glycerin enema administered rectally. A toothpick was seen to be piercing the wall of the sigmoid colon ([Fig. 2]). The available tools did not allow us to grasp the toothpick in such a way that we could free it from the sigmoid wall. We therefore attached a metal clip (HX 610-135, disposable endoscopic; Olympus Medical, Japan) to the toothpick; a polypectomy snare (Captivator, small oval, stiff, 13 mm; Boston Scientific, Costa Rica) was closed around the clip. We then used traction and countertraction movements, to remove the toothpick from the colonic wall ([Fig. 3]).

Fig. 2 Colonoscopy showed a toothpick piercing the wall of the sigmoid colon.

Fig. 3 a Clip grasping the removed toothpick. b Traction had been obtained by using the polypectomy snare closed around the clip. 

The patient progressed satisfactorily, without complications and was discharged after 48 hours. He was ingesting a bland diet, had normal bowel movements, and was taking oral antibiotics. He had no complaints at outpatient 15-day follow-up and was discharged to return to normal daily activities.

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• References

• 1 Rasslan S, Moricz A. Abdome agudo perfurativo [Perforation acute abdomen]. In: Lopes AC, Reibscheid S, Szejnfelc J, eds. Abdome agudo, clínica e imagem [Acute abdomen, clinical and imaging]. Rio de Janeiro: Atheneu; 2004: 80-94
• 2 Komninos ID, Tsiligianni IG. Foreign body ingestion mimicking irritable bowel syndrome: a case report. J Med Case Rep 2010; 4: 244
• 3 Chung YS, Chung YW, Moon SY. Toothpick impaction with sigmoid colon pseudodiverticulum formation successfully treated with colonoscopy. World J Gastroenterol 2008; 14: 948-950
• 4 Callon RA, Brady PG. Toothpick perforation of the sigmoid colon: an unusual case associated with Erysipelothrix rhusiopathiae septicemia. Gastrointest Endosc 1990; 36: 141-143