Dual site intestinal perforation due to toothpick

We present a case where a toothpick perforation in both the large and small bowel was intra-operatively diagnosed. A 45-years-old man presented with 48 hours abdominal pain associated with fever. The abdomen was tender at the McBurney point with signs of localized peritonitis. We suspected an acute appendicitis. The patient underwent a diagnostic laparoscopy. During the operation we exposed a toothpick perforating both sigmoid and small bowel. The toothpick was removed and a direct suture of the two perforations was performed. No faecal contamination or purulent peritonitis was showed. The patient was given 5 days of intravenous antibiotics and recovery was uncomplicated. Perforations caused by foreign body ingestion are often non-specific and misdiagnoses such as diverticulitis or acute appendicitis are common. The diagnosis is most commonly made on radiological imaging or intraoperatively. Abdominal X-ray is unlikely to detect a foreign body unless it is high bone density or metal, CT scan has a higher yield. In our patient, although the ultrasound didn't show directly an appendicitis, we didn't decide to perform other diagnostic exams because of the typical clinical feature. 80 to 90% of foreign bodies transit the gastrointestinal tract without causing an associated pathology. However, the distal ileum and recto sigma tract are risk areas for impaction and perforation due to their caliber. There are no guidelines for the management of foreign bodies in the lower gastrointestinal tract. Case reports describe managing patients non-operatively with antibiotics or with surgery, as in this case.