Toothpick Perforation of the Intestines Presenting as Recurrent Abdominal Pain: Possible Roles of Abdominal Ultrasound and MRI

We report the case of a middle-aged man admitted for five months of unexplained left lower quadrant pain. He had been hospitalized on two prior occasions and treated with broad spectrum antibiotics. His clinical presentation was suggestive peritoneal irritation with severe, focal pain on abdominal palpation. Computed tomography scans showed non-specific inflammation in the left lower abdomen with adjacent small bowel wall thickening. Upper endoscopy and colonoscopy were unremarkable on prior admission. Given the severity and focality of the patient's recurrent abdominal pain he underwent laparoscopy and was found to have a wooden toothpick perforation of the small bowel thirty centimeters from the ileocecal valve requiring partial small bowel resection. The patient did well post-operatively. On retrospective questioning he may have eaten a cabbage roll or bacon wrapped shrimp pierced with a toothpick weeks before the onset of symptoms. Toothpick perforation should be a consideration in edentulous persons with focal, severe abdominal pain and trans-abdominal ultrasound or MRI may be a better choice for detecting wooden foreign objects.