Toothpick perforation of small intestine in an adult

Abstract

The patient presented in Emergency with Pain right iliac fossa for last 24 hours. It was sudden in onset, mild in intensity, non-radiating to any site, and was associated with mild fever. About 5-6 episodes of vomiting occurred in that period. Her menstrual history was normal. She was taking medication for Rheumatoid Arthritis fort last three months. With Alvarado Score of 6 a clinical diagnosis of Acute Appendicitis was made. X-ray Abdomen did not reveal any abnormality, Blood C/E, Urine C/E, Blood sugar blood urea and serum electrolytes. After preparation, patient was taken to the theatre. Rutherford Morrison incision was made. Her appendix was difficult to locate but was normal. Strangely a toothpick was seen in the mesentery of appendix and there was a pinpoint perforation in terminal ileum about two inches proximal to ileocaecal junction Fig 1. Margins were fresh and it did not give a look of old perforation. There were adhesions between loops of small intestine, which were also adherent to under surface of liver. After adhesionolysis, margins of perforation were trimmed and it was repaired in two layers (Inner vicryl 2/0 continuous and outer with prolene 4/0 interrupted. Appendicectomy was also performed. After washing abdominal cavity with 0.9 normal saline wound was closed in layers. Patient was given postoperative antibiotics and an analgesic, kept NPO for 24 hours, and was discharged successfully after 3 days. Later on patient was asked and she admitted taking a burger three days earlier but she did not remember any toothpick.