title: Accidentally ingested toothpicks causing severe gastrointestinal injury: a practical guideline for diagnosis and therapy based on 136 case reports.
abstract: BACKGROUND
  Ingested toothpicks are a relatively rare event, but may cause serious gut injuries with peritonitis, sepsis, or death. Numerous case reports describing the clinical course in this setting are available but there is no concise guideline. The aim of the present study was to develop practical guidelines to aid clinicians in the diagnosis and management of acute tooth pick ingestion.
  
  
  METHODS
  Our Medline search identified 116 publications containing case reports of ingested toothpicks. We then performed a retrospective analysis of patients' characteristics, medical history, diagnostics, therapy, and clinical outcome.
  
  
  RESULTS
  A total of 136 cases (74 % male, age 52 [5-92] years) have been reported in the literature. From the available information, more than 50 % (n = 48) of patients were not aware of having swallowed a toothpick. The most common presenting symptoms were abdominal pain (82 %), fever (39 %), and nausea (31 %). The toothpick caused gut perforation in 79 % of all patients. The locations of toothpicks prior removal were esophagus (2 %), stomach (20 %), duodenum (23 %), small intestine (18 %), and large intestine (37 %). The diagnostic procedures included endoscopy (63 %), computed tomography scan (63 %), and ultrasound (47 %); however, in 35 % of cases these investigations failed to detect the toothpick. Therapy was surgery in most cases (58 %). The overall mortality was 9.6 %.
  
  
  CONCLUSIONS
  Toothpick ingestion is a medical emergency. Perforations of the intestine are common and the associated mortality is high. Adequate therapy depends on localization of the toothpick in the gastrointestinal tract. Ingested toothpicks should be kept in mind as an important differential diagnosis in patients with acute abdomen.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Catherine
authors.initials: C
authors.lastname: Steinbach
authors.forename: Martin
authors.initials: M
authors.lastname: Stockmann
authors.forename: Maximilian
authors.initials: M
authors.lastname: Jara
authors.forename: Jan
authors.initials: J
authors.lastname: Bednarsch
authors.forename: Johan Friso
authors.initials: JF
authors.lastname: Lock
mesh_terms: D000006:Abdomen, Acute / Q000209:etiology; D015746:Abdominal Pain / Q000209:etiology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D005260:Female; D005547:Foreign Bodies / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery*; D005767:Gastrointestinal Diseases / Q000601:surgery; D006801:Humans; D007416:Intestinal Perforation / Q000209:etiology; D008297:Male; D008875:Middle Aged; D055815:Young Adult