IMAGE OF THE MONTH Suppurative Duodenitis and Superior Mesenteric Vein Thrombosis After Toothpick Ingestion Benjamin W. Dorschner, Rolf W. Thouet, and Ulrich Zellweger Department of Internal Medicine, Regionalspital Surselva, Ilanz, Switzerland

28-year-old man presented to our emergency department after consulting with his general practitioner regarding abdominal cramps of 6 weeks’ duration. One week before his first consultation, he observed grey feces and had a fever (39.7 C). A clinical examination showed epigastric tenderness on palpation with localized défense musculaire (ie, abdominal guarding). Blood work showed slightly increased inflammation parameters (white cell count, 10.8109/L, C-reactive protein level, 70.4 mg/L). Ultrasound imaging detected free fluid surrounding the duodenum and the head of the pancreas. Abdominal computed tomography showed a thrombosis of the superior mesenteric vein (Figure A; red arrow, thrombus; green arrow, portal vein), which was confirmed by Doppler ultrasonography (Figure B; red arrows, thrombus in the superior mesenteric vein; green arrow, portal vein; L, liver; St, stomach). A cause could not be established by radiographic examination. Endoscopic examination of the upper intestinal tract showed a suppurative duodenitis caused by a 6.5-cm–long toothpick perforating the intestinal wall (Figure C). Pus drained out instantaneously after successful removal of the foreign body (Supplementary Video 1). Intravenous therapeutic anticoagulation was initiated for 7 days and thereafter was switched to the oral anticoagulant phenprocoumon. Three months later,

A

control examinations showed a normally perfused mesenteric vein system. A remaining thrombus was not detectable. Oral anticoagulation therapy was discontinued after 6 months. A variety of conditions are known to cause portomesenteric vein thromboses including abdominal malignancies, myeloproliferative disorders, inflammatory bowel disease, acute and chronic pancreatitis, and congenital and acquired thrombophilia.1 We present a case in which a local inflammation of the duodenum was caused by a foreign body perforating the duodenal mucosa and subsequently led to a superior mesenteric vein thrombosis. The accidental ingestion probably occurred during the Christmas holidays when eating a roulade and the patient unknowingly ingested the toothpick. There was no history of previous foreign body ingestions or aspirations. The patient’s regular alcohol consumption amounted to approximately 6 to 10 units per day, which might predispose for accidental foreign body ingestions.2 Other common risk factors (eg, dentures, edentulism, and rapid intake of insufficiently chewed food)3 were not found. Inspection of the oral cavity and endoscopy of the upper gastrointestinal tract showed no anatomic abnormalities. A neurologic examination and deglutition were normal.

Clinical Gastroenterology and Hepatology 2015;13:xxv–xxvi

IMAGE OF THE MONTH, continued Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Clinical Gastroenterology and Hepatology at www.cghjournal.org, and at http://dx.doi.org/10.1016/j.cgh.2015.01.021.

References 1.

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Wolff M, Schäfer N, Schepke M, et al. Akute und chronische Thrombosen des Pfortadersystems. Gefässchirurgie 2006; 11:188–194.

2.

Schwarz JT, Graham DY. Toothpick perforation of the intestines. Ann Surg 1977;185:64–66.

3.

Sealock RJ, Sabounchi S, Graham DY. Toothpick perforation of the intestines presenting as recurrent abdominal pain: possible roles of abdominal ultrasound and MRI. Clin Med Insights Case Rep 2013;7:131–135.

Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.021

Suppurative duodenitis and superior mesenteric vein thrombosis after toothpick ingestion.

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