# Unusual Differential Diagnosis of Upper Abdominal Pain

Authors: Lanthaler Monika; Grissmann Thomas; Schwentner Lukas; Nehoda Hermann
Journal: Diagnostic and Therapeutic Endoscopy
 (2009)

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## Abstract

We here present an interesting unusual case of upper abdominal pain. The patient was a 38-year-old man, who was admitted to our hospital complaining of right upper quadrant pain caused by a toothpick that perforated the anterior gastric wall and penetrated segment I of the liver. After endoscopic removal and an initially uneventful course, computed tomography revealed a perigastric abscess that was treated by repeated gastroscopic rinsing via an endoscopically placed catheter. After another three uneventful weeks, a liver abscess with minor tendency to constrict the portal vein was diagnosed, and a segment I liver resection together with abscess drainage was performed.
The peculiarity of this case is the rarity of toothpick ingestion and gastric perforation in a young and healthy white Caucasian followed by development of a liver abscess after primary uneventful endoscopic removal. In light of this case, gastric perforation due to ingested foreign bodies such as toothpicks can be considered a rare cause of upper abdominal pain.


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## Body

## 1. Introduction

Most accidentally ingested foreign bodies pass through
the gastrointestinal tract without difficulty. In general, perforation is very
rare and occurs in less than 1% of patients [1, 2].We here present a rare case in which an ingested
toothpick perforated the anterior gastric wall and penetrated segment I of the
liver, resulting in hepatic abscess formation.


## 2. Case Report

A 38-year-old man was admitted to our hospital with a
three-month history of upper abdominal pain. He complained of pain consistent
with gastritis, loss of appetite, and minor weight loss, but could not remember
a particular situation or time when the pain first started. Gastroscopic
findings from a different institution were unremarkable. Abdominal examination
revealed right upper quadrant pain with neither guarding nor rebound.Laboratory examination showed a white cell count of 12 200 g/dL and a C-reactive protein of 9.69 g/dL. Sonography and computed
tomography revealed a circular swelling of the anterior gastric wall up to 21 mm
in diameter and an inflammatory process reaching into the liver, but did not
identify a foreign body.To exclude the tentative radiologic diagnosis of an MALT lymphoma or a
gastric carcinoma, regastroscopy was performed.This time a toothpick perforating the anterior gastric
wall was detected that extended half of its length in the direction of the
liver (see Figure1). The toothpick was removed endoscopically using a grasper
for extricating foreign bodies (see Figure 2). The esophagus was unremarkable.Figure 1
Gastroscopy: toothpick (black arrow) perforating the
anterior gastric wall.Figure 2
Ingested toothpick.After this procedure, the patient experienced
immediate pain relief and his course was uneventful thereafter. Control
gastroscopy performed 24 hours after removal of the toothpick was normal.
Antibiotic therapy with piperacillin/tazobactam
and high-dose therapy of pantoprazole were initiated. Abdominal X-ray was
unremarkable, and laboratory signs of inflammation decreased. Four days later,
the patient was discharged.Once the diagnosis was established, a second
evaluation of the CT scan revealed a pattern possibly characteristic of a
toothpick (see Figure3).Figure 3
Computed tomography image with a pattern possibly revealing a toothpick
(black arrow).After discharge, the patient was closely monitored in outpatient
check-ups. Antibiotic therapy with cefuroxime was maintained for one more week,
and the patient’s course was uneventful for two weeks.Thereafter,
the patient again presented with right upper quadrant pain, and laboratory
findings indicated severe inflammation. Computed tomography revealed a
perigastric abscess that was successfully treated by gastroscopic rinsing. A
catheter was endoscopically inserted in the perigastric abscess several times,
and through this catheter we rinsed the abscess cavity every time the catheter
was introduced. Since this was a unique case, the method was experimental.
Treatment of such an abscess using antibiotics alone would have been
ineffective. Before finally deciding to operate, we wanted to try gastroscopic
rinsing, because it would be much less invasive than an operation and the
location of the abscess was optimal for such treatment.After gastroscopic rinsing,
the patient was symptom free and showed no signs of inflammation. Moreover,
computed tomography was unremarkable, so that we could reasonably presume at
that time that treatment was successful.After another three uneventful weeks, the patient was
admitted again. Once more he complained of right upper quadrant pain, and this
time laboratory findings showed leukocytosis to be 18 000 g/dL and C-reactive
protein 60 g/dL. Blood cultures remained sterile. Computed tomography revealed
a liver abscess mainly in the lobus caudatus with a slight tendency to
constrict the portal vein. The abscess was riddled with septa, so that puncture
was not possible. Antibiotic therapy with piperacillin/tazobactam was initiated again, and
an operative abscess drainage and segment I resection through laparotomy
finally performed. The abscess was 6 cm in diameter, and anatomical resection of
the entire caudate lobe was necessary. The microbiological findings revealedStreptococcus milleri for the abscess material. The intraoperatively placed drain was left in place
for five days. The patient’s subsequent course was uneventful, and he was
discharged symptom free after two more weeks. The patient has remained symptom free
until today.


## 3. Discussion

As described in the literature, the majority of
foreign bodies transit through the gastrointestinal system without causing
complications. The esophagus and the colon are the two main localizations at the
highest risk for perforation. The literature contains only few reports of
perforation of the gastric wall, usually involving peritonitis that is
subsequently treated by laparoscopy or laparotomy [3–5].From this case, we see that the initially benign
course of a gastric perforation due to a toothpick can ultimately become a
severely dangerous situation, as when our patient developed a liver abscess. If
such an abscess cannot be drained percutaneously because of septa or adverse
localization, immediate surgical removal is mandatory to prevent a
life-threatening situation like a portal vein thrombosis.



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*Source: 817052-2009-02-16.xml*