A swallowed toothbrush causing perforation 2 years after ingestion

Abstract

A 33-year-old woman presented with a 3-day history of abdominal distension, ten-out-of-ten abdominal pain and rigors. She had had her bowels open every day since the onset of the pain, and her stools were normal. She had vomited once on the day of presentation. She mentioned she had been in a tussle with another person 3 days previous, and her pain had come on after this. She looked unwell, and was found to be hypotensive and tachycardic. Abdominal examination showed generalized tenderness and a tightly distended abdomen. There was no overt guarding and bowel sounds were normal. There was a palpable hardness in the right upper quadrant, which the patient identified as a toothbrush which she had swallowed 2 years previously as a suicide attempt. She said that it often gave her some discomfort but never anything like the pain she was experiencing at presentation. She had refused intervention to remove it at the time of ingestion and ever since. Erect chest radiography (Figure 1) revealed a large amount of free gas under both hemidiaphragms, and the bristles of a toothbrush to the right of the midline below the diaphragm. Arterial blood gas sampling showed a profound acute metabolic acidosis. The patient was taken to emergency theatre for a laparotomy. In theatre a 1.5 cm prepyloric anterior ulcer was found, and the toothbrush was removed, head-first, having been lying transversely in the stomach. The patient made a slow recovery and was discharged from hospital a month after initial admission, having suffered episodes of adult respiratory distress syndrome and hypoalbuminaemia-related pleural effusion before discharge.