Foreign body presenting as a duodenal mass: Case report and literature review

Importance: An abnormal clinical presentation of foreign body ingestion and its therapeutic approach. Review of the literature to determine rate of perforation along the gastrointestinal tract by foreign body ingestion and to identify appropriate diagnosis and treatment of ingested foreign bodies in the duodenum. Observations: A case report of a 57-year-old female presenting with abdominal pain, chest pain, and headaches for two days. With computed tomography imaging, findings of an intraluminal mass in the duodenum and retroperitoneal air were identified, leading to suspicion of a perforated duodenal malignancy. On endoscopic ultrasound, a toothpick was identified protruding through the wall of the third portion of the duodenum, which was removed by upper endoscopic forceps. A review of the literature yielded 236 cases of foreign body perforation of the gastrointestinal tract between the years 2000 to 2015 in adults 18 years and older. Perforation rate of the small bowel was highest at 39.8% followed by the duodenum 22%, colon 20.3%, sigmoid 5.5%, and unidentified site 1.7%. Literature analysis for therapeutic options for gastrointestinal injury by foreign body ingestion included endoscopy, laparotomy, or laparoscopy. A diagnostic therapeutic algorithm for duodenal foreign body ingestion was created. Conclusions: Ingested foreign bodies can present with a variety of clinical symptoms. Thus, they should be considered as part of a differential diagnosis for cases with gastrointestinal symptoms without clear etiology. Even with imaging studies, foreign body ingestion can be difficult to diagnose initially. Sharp objects, especially toothpicks, have an increased rate of perforation of the gastrointestinal tract and have a high associated morbidity and mortality. As such, prompt diagnosis and management are necessary to improve outcomes.