3065 Foreign Body Colonic Perforation: Considerations Beyond the Colon

Abstract

INTRODUCTION: Toothpick ingestion may cause gastrointestinal tract perforation; associated injury of extracolonic vasculature or soft-tissue is rarely reported. We present a case of toothpick related sigmoid colon perforation and associated internal iliac artery injury requiring sigmoid colon resection. CASE DESCRIPTION/METHODS: A 44-year-old male with Marfan syndrome and COPD presented to our hospital with progressive right hip pain for a week. On physical exam he was febrile, tachycardic, and had tenderness of his right lateral thigh. He was found to have a leukocytosis of 18k, as well as an elevated ESR and CRP. Blood cultures grew Bacteriodes. An abdominal CT showed a right psoas abscess and a thin, dense linear structure extending from the distal sigmoid colon, through the right internal iliac artery, and terminating just anteromedial to the right sacroiliac joint. IV antibiotics were initiated. Interventional radiology performed a CT guided abscess drainage. GI was consulted as there was suggestion of a sigmoid fistula/foreign body on imaging. The patient had no recollection of ingestion of a foreign body. Flexible sigmoidoscopy showed a foreign body traversing the wall of the distal sigmoid colon (Figure 1). It was not removed endoscopically due to perforation through the colonic wall, as it was unclear what was on the extra luminal side of the object. Colorectal surgery was consulted and he urgently underwent a hand-assisted laparoscopic partial sigmoid resection on the same day. Intraoperative findings showed a perforation of the distal sigmoid colon due to a toothpick with associated injury to internal iliac artery. The affected portion of the sigmoid colon with the toothpick was removed laparoscopically, after which there was noted to be pulsatile bleeding from the internal iliac artery that resolved with manual pressure for 20 minutes. The iliac artery was subsequently repaired and a primary colonic anastomosis was performed. Gross operative specimen is shown in Figure 2. Post-operative course was uncomplicated and the patient was discharged home in stable condition. DISCUSSION: Ingestion of sharp pointed objects such as toothpicks pose a significant risk of organ injury. We demonstrate a case of an ingested toothpick resulting in a perforation through the sigmoid colon and the internal iliac artery, presenting initially as a psoas abscess. This was successfully treated surgically and the patient did well post-operatively.