Ascending colon toothpick impaction identified during screening colonoscopy: A case report

Abstract

BACKGROUND

Toothpick ingestion is uncommon but potentially dangerous due to their sharp pointed ends and, for wooden toothpicks, their radiolucent nature, which evades imaging detection. Delayed diagnosis may lead to localized infection, obstruction, or perforation. This case highlights diagnostic limitations and successful endoscopic management of an ascending colon embedded wooden toothpick.

CASE SUMMARY

A 53-year-old man with hypertension, diabetes mellitus, hyperlipidemia, and obesity underwent initial screening colonoscopy. Of note, he presented 3 weeks prior to the emergency department with acute abdominal pain and leukocytosis. Contrast-enhanced computed tomography demonstrated small bowel obstruction with a suspected right mid abdomen transition point but no perforation. Symptoms resolved with supportive care. During colonoscopy, a wooden toothpick was found embedded in the ascending colon with purulent discharge. The toothpick was removed using a snare, and a hemoclip was deployed. Post-procedure imaging showed no perforation, and he recalled potentially swallowing a toothpick the day prior to his emergency department visit. The patient remained asymptomatic at 2-week follow-up. This case is notable for incidental discovery during screening colonoscopy following a prior negative computed tomography (CT) evaluation.

CONCLUSION

Sharp foreign bodies, such as toothpicks, can cause localized inflammation, perforation, or abscess formation if lodged within the gastrointestinal tract. The ascending colon is a rare site for that, and diagnosis is often delayed due to nonspecific symptoms along with object imaging radiolucency. In this case, the toothpick may have been associated with his prior abdominal symptoms, though undetected on CT. This highlights limitations in identifying ingested sharp objects as well as the importance of clinical suspicion in patients with unexplained abdominal symptoms. Endoscopic removal, when feasible, is effective and safe.

Key Words: Toothpick; Foreign bodies; Colonoscopy; Small bowel obstruction; Colonic perforation; Case report

Core Tip: Wooden toothpicks are radiolucent and may be missed on imaging, leading to delayed diagnosis. This case demonstrates ascending colon toothpick impaction discovered during screening colonoscopy after a prior episode of acute abdominal pain with computed tomography suggestive of obstruction. Endoscopic removal was successful without complication, emphasizing the importance of clinical suspicion and timely endoscopic evaluation.

INTRODUCTION

Foreign body ingestion is frequently encountered in clinical practice. Although most ingested objects pass spontaneously, sharp-pointed objects such as toothpicks carry a significant risk of mucosal penetration, abscess formation, and perforation[1]. Wooden toothpicks pose a diagnostic challenge because they are often radiolucent and patients frequently do not recall ingestion. Imaging may demonstrate secondary inflammatory changes rather than the object itself[2,3].

We report a case of ascending colon toothpick impaction discovered incidentally during screening colonoscopy following a prior episode of abdominal pain and leukocytosis with inconclusive imaging findings.

CASE PRESENTATION

Chief complaints

The patient was a 53-year-old male presenting for his index screening colonoscopy and was asymptomatic at the time.

History of present illness

Three weeks prior, the patient presented to the emergency department with acute abdominal pain and chills. Laboratory evaluation revealed leukocytosis. Computerized tomography (CT) imaging suggested a small bowel obstruction with a transition point in the right mid abdomen, without evidence of perforation. His symptoms resolved with supportive care, and he was discharged. At the time of subsequent screening colonoscopy, he was asymptomatic.

History of past illness

Hypertension, type 2 diabetes mellitus, hyperlipidemia, obesity.

Personal and family history

The patient was a Hispanic male born in El Salvador and currently unemployed. He had no history of denture or dental prosthesis use. In addition, there was no reported family history of colorectal cancer.

Physical examination

On physical examination vital signs were as follows: Temperature 35.7 °C, pulse 95 beats/minute, respiratory rate 20 breaths/minute, blood pressure 124/80 mmHg and oxygen saturation of 97%. On exam of the abdomen there was mild diffuse tenderness without rebound or guarding. The remainder of the exam was without significant findings.

Laboratory examinations

Laboratory evaluation demonstrated leukocytosis (white blood cell: 12.2 × 10⁹/L) with neutrophil predominance. Mild relative lymphopenia was noted, likely representing a reactive response in the setting of acute illness. Other laboratory values, including metabolic profile and liver enzymes, were within normal limits.

Imaging examinations

Initial CT of abdomen and pelvis with contrast in emergency room showed small bowel obstruction with suspected transition point in the right mid abdomen. No free air or free fluid seen. Post-colonoscopy abdomen and pelvis CT showed endoclip at hepatic flexure without perforation or inflammatory changes.

FINAL DIAGNOSIS

Ascending colon wooden toothpick impaction with localized purulent inflammation.

TREATMENT

Endoscopic removal using a snare device with hemoclip placement at extraction site. Post-procedure observation and CT imaging as mentioned above (Figure 1).

Figure 1 Ascending colon toothpick impaction and management. A: Embedded toothpick in the ascending colon with purulent discharge at the insertion site (orange arrow); B: Endoscopic snare retrieval of the foreign body; C: Retrieved toothpick following successful extraction; D: Follow-up imaging demonstrating clip placement at the retrieval site, with no evidence of perforation or other complications (yellow circle).

OUTCOME AND FOLLOW-UP

No evidence of perforation or fluid collection on repeat imaging. The patient was asymptomatic at 2-week post procedure clinic follow-up (Table 1).

Table 1 Clinical timeline of events.

Date	Event	Findings	Management
February 2025	Emergency department visit	Abdominal pain, WBC 12.2 × 109/L; CT suggestive of small bowel obstruction	Supportive care
3 weeks later	Screening colonoscopy	Toothpick embedded in ascending colon with purulence	Endoscopic removal + hemoclip
Same day as colonoscopy	Post-procedure CT	Clip visualized; no perforation	Observation
2-week post procedure follow-up	Clinic visit	Asymptomatic	No further intervention

WBC: White blood cell; CT: Computed tomography.

No antibiotics were administered, as there was no clinical or radiographic evidence of systemic infection.

DISCUSSION

Accidental ingestion of foreign bodies is a common clinical scenario; however, ingestion of wooden toothpicks represents a particularly high-risk subset because of their sharp structure and radiolucent composition. Unlike metallic or calcified objects, wooden toothpicks are frequently undetectable on routine radiography and may also be difficult to visualize on contrast-enhanced abdominal CT[1,2]. Toothpick ingestion is associated with a disproportionately high rate of gastrointestinal injury compared with other ingested foreign bodies, with reported complications including abscess formation, fistula development, bowel obstruction, sepsis, and death[4-6].

In the present case, the patient initially presented with abdominal pain and leukocytosis, and CT imaging suggested small bowel obstruction with a suspected transition point but no identifiable foreign body. This diagnostic limitation has been well described. Wooden foreign bodies may appear as subtle linear densities or remain entirely invisible depending on their orientation, hydration state, and surrounding inflammatory changes[2,3,7]. As a result, CT may reveal only indirect findings such as bowel wall thickening, inflammatory fat stranding, or obstruction without clear visualization of the offending object[3,8]. This likely explains the discrepancy in our case between imaging findings suggestive of obstruction and the absence of a detectable foreign body.

The discrepancy between CT findings suggesting small bowel obstruction and subsequent identification of the toothpick in the ascending colon warrants consideration. Possible explanations include distal migration of the foreign body between imaging and colonoscopy, transient obstruction related to localized inflammation, or a nonspecific CT finding unrelated to a fixed obstruction. Given the known limitations of CT in detecting radiolucent objects, indirect inflammatory changes may have contributed to the initial interpretation[2,3,7,8].

Another important challenge in diagnosis is that patients frequently do not recall ingesting toothpicks. Previous studies have shown that a substantial proportion of affected individuals are unaware of the ingestion event[4,9]. Reported risk factors include denture use, rapid eating, alcohol consumption, and certain cultural dietary practices[9,10]. Notably, our patient had none of these classical risk factors and did not recall ingestion, illustrating that the absence of these factors does not exclude the diagnosis.

The patient’s recollection of possible toothpick ingestion prior to the emergency department visit suggests a prolonged intraluminal presence of approximately three weeks before detection. While sharp foreign bodies often lead to early complications, delayed presentations without perforation have been described in the literature[4,5]. The presence of localized purulence in this case may reflect a more chronic inflammatory process rather than an acute event, although the absence of systemic signs suggests a contained process; however, endoscopic appearance did not allow reliable estimation of the duration of intraluminal exposure.

The ascending colon location of impaction in this case is clinically relevant. Sharp foreign bodies tend to lodge at sites of anatomic narrowing or angulation, such as the ileocecal valve, hepatic flexure, or rectosigmoid junction[11]. Colonic toothpick impaction has been reported to mimic a variety of conditions including appendicitis, diverticulitis, inflammatory bowel disease, and neoplasm[12,13]. In some cases, delayed diagnosis leads to transmural perforation and localized or generalized peritonitis[5,14].

The patient’s use of naproxen may have contributed to localized mucosal vulnerability, as nonsteroidal anti-inflammatory drugs are associated with gastrointestinal mucosal injury, inflammation, and ulceration. While this may have facilitated mucosal penetration or exacerbated local inflammation, it is unlikely to represent the primary cause of impaction. The observed lymphopenia was mild and likely reactive in the setting of acute illness, with no clinical features to suggest underlying immunodeficiency.

Endoscopic management remains the preferred therapeutic approach when feasible. Current guidelines recommend prompt removal of sharp foreign bodies accessible by endoscopy to minimize the risk of perforation[1,15]. Various retrieval devices, including snares, forceps, and retrieval nets, have been successfully used for this purpose[16,17]. In our case, removal was achieved using a snare device followed by hemoclip placement at the extraction site. Clip placement is commonly used when concern for mucosal injury exists[1,9].

Post-procedure imaging confirmed the absence of perforation or intra-abdominal fluid collection. Although routine CT imaging after endoscopic removal is not universally required, it may be appropriate in cases where mucosal injury, purulence, or technically difficult extraction raises concern for deeper mural injury. Careful outpatient follow-up is also recommended because delayed perforation has been reported in rare instances[5,14].

This case highlights three key clinical considerations: (1) Radiolucent foreign bodies such as wooden toothpicks may not be visualized on CT imaging; (2) Clinical suspicion should remain high in patients with unexplained abdominal symptoms despite negative imaging; and (3) Endoscopy plays a central role in both diagnosis and management of accessible foreign bodies[1,16].

CONCLUSION

Radiolucent foreign body ingestion presents a diagnostic challenge due to limitations of imaging and nonspecific clinical presentation. Endoscopy enables diagnosis and management in select cases when suspicion persists despite inconclusive imaging.