Abdominal distention

Abstract

A 41-year-old man with a history of congenital mental retardation was admitted because of newly diagnosed diabetes mellitus with hyperosmolar hyperglycemic state. A kidney ureter bladder radiograph for abdominal distention demonstrated a radio-opaque lesion (Figure 1A, arrow) superimposed over the right psoas muscle. Coronal reformatted computed tomography image of the contrast-enhanced abdominal scan showed an irregular high-density mass inside the third portion of the duodenum (Figure 1B, white arrow), with a radiolucent lesion extending from the bulb to the second portion of the duodenum (Figure 1B, black arrow). Esophagogastroduodenoscopy demonstrated a toothbrush in the bulb, with the toothbrush head in third portion of duodenum. The toothbrush was removed by the following endoscopic procedure of three steps. First, we pulled the distal end of toothbrush into the stomach by a snare (Cook Medical, Bloomington, IN). Second, the toothbrush head was pulled into the stomach by a foreign body retriever (Olympus FG-44NR-1, Tokyo, Japan). Third, the toothbrush (19 cm in length) was pulled out from stomach by a snare smoothly (Figure 2). The differential diagnosis of a radio-opaque lesion of abdomen may include: calcified bezoar, artificial teeth, soft tissue mass with calcification, or a radiolucent foreign body with a metallic part. A characteristic radiographic image of a toothbrush showed parallel rows of short metallic radiodensities due to the metallic plates with the bristles. Foreign bodies longer than 10 cm cannot pass through the duodenal C-loop due to its fixed retroperitoneal position.1 These objects should be removed by endoscopy as soon as possible to prevent pressure necrosis and perforation of the gastrointestinal tract.2 Laparoscopic gastrotomy should be performed if endoscopic removal fails.