Successful removal of a toothpick penetrating the sigmoid colon by low-pressure endoscopy using the gel immersion method

Foreign bodies with sharp edges such as toothpicks in the gastrointestinal tract may cause injury [1]. Foreign bodies in the colon are preferably removed by colonoscopy, but bowel preparation should be avoided with suspected penetration. Gel immersion endoscopy can provide a clear view even without bowel preparation [2] while maintaining low intraluminal pressure [3] [4].

The patient was an 8-year-old boy who inserted a wooden toothpick into his anal canal. The patient developed abdominal pain within 12 hours. Laboratory tests showed an elevated white blood cell count and C-reactive protein level. Contrast-enhanced computed tomography scan demonstrated a 65-mm rod-shaped foreign body piercing the sigmoid colon with an extraluminal micro-abscess and panniculitis ([Fig. 1]). Without bowel preparation, we performed a sigmoidoscopy using a transparent hood ([Video 1]). After aspiration of the residual gas, VISCOCLEAR gel (Otsuka Pharmaceutical Factory, Tokushima, Japan) was injected through the accessory channel to secure the visual field without gas insufflation. The toothpick was found in the sigmoid colon ([Fig. 2]). After grasping its end with a snare and retracting it into the transparent hood ([Fig. 3]), we removed the endoscope ([Fig. 4]). We reinserted the endoscope and found a small amount of pus in the lumen, which entered through a small pit ([Fig. 5]). Endoscopic closure was not performed because the small pit provided drainage. We placed a clip to mark the pit. The patient recovered by maintaining non per os and antibiotic administration without surgical intervention.

Fig. 1 Contrast-enhanced computed tomography scan demonstrated a 65-mm rod-shaped foreign body (i. e., toothpick) penetrating the sigmoid colon.

Video 1 Successful removal of a toothpick penetrating the sigmoid colon by low-pressure endoscopy using the gel immersion method.

Fig. 2 The toothpick was found in a clear endoscopic view by the gel immersion method even without bowel preparation or gas insufflation.

Fig. 3 The end of the toothpick was grasped with a snare to remove it.

Fig. 4 The entire toothpick was removed from the patient.

Fig. 5 A small amount of pus entered the lumen through a small penetration pit.

The use of low intraluminal pressure during gel immersion endoscopy is supported by extraluminal pus that entered the lumen through the penetration site. Therefore, gel immersion endoscopy is suggested to be useful for retrieval of sharp foreign bodies after penetration of the colonic wall while securing the visual field without the need for increased intraluminal pressure that could aggravate the abscess.

Endoscopy_UCTN_Code_CCL_1AG_2AZ

• References

• 1 Zouros E, Oikonomou D, Theoharis G. et al. Perforation of the cecum by a toothpick: report of a case and review of the literature. J Emerg Med 2014; 47: e133-e137
• 2 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811
• 3 Yano K, Yano T, Nagayama M. et al. Hemostasis of an actively bleeding lesion at the ileocecal valve by low-pressure endoscopy using the gel immersion technique. VideoGIE 2021; 6: 184-186
• 4 Sekiguchi H, Yano T, Tokoro S. et al. Low-pressure endoscopy using the gel immersion method facilitates endoscopic variceal ligation of ruptured esophageal varices. Endoscopy 2021;