Foreign Body Ingestion of a Toothbrush
A 15-year-old girl presented to the emergency department (ED) 1 hour after having swallowed her toothbrush. The patient stated that she had been brushing her teeth and, as she tilted her head back, the toothbrush “fell in.” She quickly developed throat, midsternal chest, and abdominal pain, which prompted her to come to the ED. She reported no vomiting, gagging, stridor, drooling, or difficulty breathing. Other than intermittent asthma, the patient had no documented medical, surgical, or psychiatric history. In the ED, her vital signs were stable, and physical examination findings were unremarkable.
Soft tissue neck and chest radiographs showed no evidence of a radiopaque foreign body. However, an abdominal radiograph showed multiple small radiopaque densities in the right upper quadrant, which were consistent with an ingested foreign body (A and B). A noncontrast computed tomography (CT) scan of the abdomen and pelvis revealed small metallic objects arranged in parallel rows. This finding was consistent with an ingested toothbrush whose head was in the distal stomach/proximal duodenum, and whose handle remained in the lumen of the stomach.
Preoperative laboratory test results were unremarkable. A psychiatric consultation was ordered in the ED. The patient was transferred to the operating room and placed under general anesthesia. She underwent esophagogastroduodenoscopy, but numerous attempts failed to remove the toothbrush. She then underwent laparoscopic gastrotomy, during which the toothbrush was removed.
After successful gastrotomy, the patient was admitted to the inpatient unit for observation. Her subsequent hospital course was uneventful. She began oral feeding on postoperative day 2. Psychiatric evaluation results showed no evidence of eating disorders, psychiatric conditions, or behavioral problems, and the patient was discharged home on postoperative day 5.
Cases of foreign body ingestion are common in pediatric EDs, with a peak incidence in patients between the ages of 6 months and 6 years.1 Most cases in this age group result from normal exploratory behavior, and the most commonly ingested foreign bodies among this population are inanimate objects such as coins, buttons, batteries, and magnets.
Mortality rates from foreign body ingestion are extremely low. A compilation of numerous studies reported no deaths among 852 adults and 1 death among 2,206 children.1 The need for and timing of an intervention depend on the patient’s age and clinical condition; the size, shape, type and anatomic location of the ingested object(s); and the time since ingestion.1 Most ingested foreign objects pass without the need for intervention.1 Ingestion of a button battery with mucosal entrapment and ingestion of multiple magnets are associated with the highest risk of complications.1
While most cases among infants and young children are accidental, adolescents may swallow foreign bodies intentionally. Adolescents with foreign body ingestion typically have predisposing factors such as intellectual impairment, psychiatric illnesses, or eating disorders.1,2 Swallowing of a toothbrush is extremely rare, with only approximately 50 cases reported in the literature.3 An ingested toothbrush presents a unique clinical challenge due to its inability to spontaneously pass through the gastrointestinal tract.
Most toothbrush ingestions are seen in adolescent girls who have a diagnosis of bulimia or anorexia nervosa.4 A person with an eating disorder may use the handle of the toothbrush to induce vomiting. A clue to this diagnosis is a toothbrush ingested with the handle distally and the bristles proximally.4-6 In our patient, the bristles were found distally and the handle proximally, which is more suggestive of an accidental ingestion.
Toothbrushes have a characteristic appearance on radiographs: small metallic densities arranged in parallel rows. These metallic densities represent the metallic plates that hold the bristles in place.5 Toothbrushes have been found in the esophagus, stomach, and duodenum.6,7 Unlike with most other ingested foreign bodies, there are no reports in literature of spontaneous passage of a swallowed toothbrush8; this is due to the object’s relatively large size. Prompt removal from the gastrointestinal tract is advised to minimize complications such as impaction (which usually occurs in the pylorus or the second part of the duodenum), gastritis, ulceration, and perforation and subsequent peritonitis.4,8
Toothbrushes may get entrapped in the duodenum. The duodenum contains relatively fixed angulations at the junction of the second and third portions, and at the suspensory muscle. Long, thin objects are prone to become impacted at these sites.1 In infants, objects of only 2 to 3 cm may become lodged in the second portion of the duodenum, while older children and adolescents may pass objects of as much as 5 to 6 cm.1 Regardless of a patient’s age, endoscopic removal is recommended for most objects greater than 6 cm.1
In our case, the toothbrush not only was longer than 6 cm, but also was lodged proximal to the duodenum, and thus urgent endoscopic removal was indicated.1 Successful removal of toothbrushes has been described with the use of both rigid endoscopy and fiberoptic endoscopy under local or general anesthesia.7,9 However, because of a toothbrush’s irregular shape, endoscopic removal may not be successful. In these situations, if complications are not present, a laparoscopic approach may be attempted.9 If complications are present, laparotomy with gastrotomy or duodenotomy may be required.7 When a toothbrush is lodged horizontally in the gastric body and outlet, the shape of the stomach may preclude endoscopic removal. In these cases, the surgeon/endoscopist must be prepared to proceed to gastrotomy.4 n
REFERENCES
1. Ikenberry SO, Jue TL, Anderson MA, et al; ASGE Standards of Practice Committee. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091.
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(8):1001-1005.
3. Oliveira SC, Slot DE, van der Weijden F. Is it safe to use a toothbrush? Acta Odontol Scand. 2014;72(8):561-569.
4. Wilcox DT, Karamanoukian HL, Glick PL. Toothbrush ingestion by bulimics may require laparotomy. J Pediatr Surg. 1994;29(12):1596.
5. Riddlesberger MM Jr, Cohen HL, Glick PL. The swallowed toothbrush: a radiographic clue of bulimia. Pediatr Radiol. 1991;21(4):262-264.
6. Faust J, Schreiner O. A swallowed toothbrush. Lancet. 2001;357(9261): 1012.
7. Sachdeva OP, Gulati SP, Kakker V, Sachdeva A, Mishra DS, Sekhon MS. Unusual foreign body in the duodenum. Indian J Gasteroenterol. 1994; 13(1):33.
8. Kirk AD, Bowers BA, Moylan JA, Meyers WC. Toothbrush swallowing. Arch Surg. 1988;123(3):382-384.
9. Wishner JD, Rogers AM. Laparoscopic removal of a swallowed toothbrush. Surg Endosc. 1997;11(5):472-473.