Toothpick-induced aortoenteric fistula presenting as sepsis

Abstract

Aortoenteric fistulas (AEF) are a rare but life-threatening cause of gastrointestinal (GI) bleeding. We present the case of a primary AEF caused by ingestion of a toothpick by a 47-year-old male. This is the 10th known case in the literature in which a foreign body was found to be the cause of a communication between the aorta and the GI tract. Most foreign objects have been sewing needles; this is the first known case of a toothpick penetration. The patient presented to our institution with polymicrobial sepsis and bilateral pulmonary septic emboli. The patient was successfully treated but required multiple interventions and a prolonged intensive care unit admission.

Bacteremia Associated With a Toothpick Lodged in the Duodenal Wall

“…The literature review has found highly varying symptoms from hematochezia to abscess formation, and fistula formation to aortoenteric fistula. In our case, the majority of patients (82%) reported just abdominal pain [ 3 ].…”

“…The most common sites of impaction are reported to be the esophagus (2%), stomach (20%), duodenum (23%), small intestine (18%), and large intestine (37%) [ 8 ], but the literature review also reveals reports where the toothpick was found in the liver, pancreas, kidney, heart, bladder, ureter, and vasculature [ 4 , 9 , 10 ]. It can also lead to the formation of a fistula and pseudo-diverticulum as well as an abscess in different viscera [ 3 , 11 ]. These non-specific symptoms present a nightmare scenario for physicians and often lead to misdiagnosis.…”

“…Toothpick ingestion, specifically, is a relatively rare phenomenon and accounts for 8-9% of all ingested foreign bodies [ 2 ]. Its non-specific symptoms, inability to recall toothpick ingestion in up to 50% of cases [ 3 ], and its radiolucent nature makes it difficult to diagnose on routine investigations [ 4 ]. Ingestion of a toothpick carries a high mortality risk and may result in GI tract perforation as well as other serious consequences [ 5 ], with one study reporting a mortality rate of up to 18% [ 6 ].…”

Aortoenteric fistula: Case series from a tertiary center in Taiwan

“…Gastrointestinal tract problems, such as malignancy, peptic ulcer disease, duodenal diverticulum, pancreatic pseudocyst, foreign body, or Billroth II gastric resection, may also contribute to secondary AEF. [3][4][5][6][7][8] Secondary AEF is more common than the primary type, although both are rare. The incidence of secondary AEF following aortic surgeries was reported to be 1.6% in a 36-year population-based study.…”

“…Secondary AEF most commonly occurred in patients who had previous aortic surgery, with/without aortic prosthesis. Gastrointestinal tract problems, such as malignancy, peptic ulcer disease, duodenal diverticulum, pancreatic pseudocyst, foreign body, or Billroth II gastric resection, may also contribute to secondary AEF 3–8 . Secondary AEF is more common than the primary type, although both are rare.…”