Endoscopic removal of accidentally ingested adult tooth brush

Ingestion of foreign bodies and impaction of food boluses frequently require endoscopic intervention. The most common ingested foreign bodies include food, fish and chicken bones, medication packaging, dentures, and coins [1]. An adult sized toothbrush is infrequently ingested, and a literature review of prior cases reveals adults who ingest it often have psychiatric co –morbidities [2]. There are no reported cases of a toothbrush passing through the gastrointestinal tract spontaneously and removal is recommended to prevent complications. Endoscopic retrieval is recommended and if unsuccessful, a laparoscopic or surgical approach is recommended. We present a 23 year old woman who reportedly accidently ingested an adult sized toothbrush. Initial attempt at endoscopic retrieval was unsuccessful due to inability to traverse the toothbrush past the gastro-esophageal junction. Subsequently with the use of a long overtube, successful endoscopic retrieval was achieved. The patient tolerated both procedures well and was discharged home subsequently. This case illustrates the importance of using a longer (45 cm) over-tube that extends beyond the gastro-esophageal junction, in endoscopic retrieval of ingested long foreign bodies such as a toothbrush. A review of the literature about the timing and techniques of endoscopic removal of ingested long foreign bodies as well as complications will be discussed. Correspondence to: Sarfaraz Jasdanwala, Department of Internal Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA, Tel: 732-923-5000, ext 1450; E-mail: s.a. jasdanwala@gmail.com Received: April 06, 2015; Accepted: May 04, 2015; Published: May 07, 2015 Case Presentation A 23 year old woman with no past medical history presented to the emergency department after accidentally swallowing an adult sized toothbrush. After eating excess amount of food at a party on the evening of admission, she was uncomfortable with the large volume of food ingested and reportedly used the back of an adult sized 7.5inch toothbrush to induce emesis. During this process, she reported losing control of the object and accidentally swallowed the adult sized toothbrush. The patient denied subjective complaints including chest and abdominal pain, discomfort, nausea or vomiting. She did not feel the toothbrush getting stuck at any point and reported it passed without difficulty. There was no reported past history of eating disorders. She denied any suicidal ideation. Past medical history, family history and social history were reviewed and found to be unremarkable. Physical exam was unremarkable. The abdomen was soft and non– tender. There was no parotid gland enlargement or erosions of the lingual surface of the teeth, loss of enamel, periodontal disease, and extensive dental caries. Labs including complete blood count, basic metabolic panel, prothrombin time (PT) and partial thromboplast intime (PTT) were within normal limits. X-ray Abdomen showed the toothbrush head bristles within the gastric fundus (Figure 1). X-ray of the neck revealed normal soft tissue shadow and patent airways. Decision was made to retrieve the toothbrush endoscopically. Initial endoscopic retrieval was attempted in the operating room at midnight using polypectomy snare and rat tooth forceps but this was unsuccessful due to inability to introduce the toothbrush into the esophagus. The toothbrush was visualized in the fundus in a pool of residual liquid and solid food material. The bristled end was facing the pylorus and therefore the snare was used to rotate the toothbrush so that the bristled end was now proximal. The snare was firmly on the bristles but the toothbrush did not traverse through the gastroesophageal (GE) junction, despite different maneuvers including Figure 1. X-ray abdomen showing toothbrush bristles. Jasdanwala S (2015) Endoscopic removal of accidentally ingested adult tooth brush Volume 1(4): 70-72 Clin Case Rep Rev, 2015 doi: 10.15761/CCRR.1000125 Glucagon. The procedure was abandoned after 2 hours. A subsequent attempt was made the following morning using a long flexible overtube. A two channel (T2) endoscope was utilized and with a snare the endoscopist was able to grab the bristled end of the toothbrush and drag it into the over-tube. Once in the over-tube, the bristles of the toothbrush were grabbed with a rat tooth forceps and the toothbrush was successfully removed from the patient. The second procedure also took two hours, mostly due to the presence of a significant amount of food making visualization and maneuvering difficult (Figures 2 and 3). The patient did well post procedure and was discharged to home later on the same day after being monitored under observation for 10 hours.