Introduction: Foreign body ingestion is a common presenting complaint in the emergency department. While ingestion of small foreign bodies like coins and button batteries is not uncommon, ingestion of long and rigid foreign bodies like toothbrush is very rare.&nbsp;Case presentation: We describe a 36-year-old man who presented to us after accidental ingestion of a toothbrush. The patient underwent urgent endoscopic removal; Psychiatric evaluation revealed an acute and transient psychotic disorder in him.&nbsp;Conclusion: Ingestion of long and rigid foreign bodies like a toothbrush is an uncommon entity. Such foreign bodies when ingested find it difficult to maneuver through the GI tract, which makes their spontaneous passage almost impossible. Their ingestion is associated with increased risk of impaction, perforation and, bleeding. Therefore, early removal of the ingested toothbrush is recommended before complications develop

Aggarwal, Praveen

B, Nayan H

Kaushal, Kanav

Mathew, Roshan

Mohindra, Ritin

Rout, Gyan Ranjan

English

Advanced Journal of Emergency medicine

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e78 Mohindra et al 
   
 1 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
Case Report DOI: 10.22114/ajem.v0i0.275 
An Unusual Case of Accidental Ingestion of a Toothbrush 
  
Ritin Mohindra1, Nayan HB2, Roshan Mathew2*, Gyan Ranjan Rout 3, Kanav Kaushal3, Praveen Aggarwal2 
 
1. Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India. 
2. Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India. 
3. Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India. 
 
*Corresponding author: Roshan Mathew; Email: roshmat15@gmail.com 
Published online: 2019-10-10 
Abstract  
Introduction: Foreign body ingestion is a common presenting complaint in the emergency department. 
While ingestion of small foreign bodies like coins and button batteries is not uncommon, ingestion of long 
and rigid foreign bodies like toothbrush is very rare. 
Case presentation: We describe a 36-year-old man who presented to us after accidental ingestion of a 
toothbrush. The patient underwent urgent endoscopic removal; Psychiatric evaluation revealed an acute and 
transient psychotic disorder in him.  
Conclusion: Ingestion of long and rigid foreign bodies like a toothbrush is an uncommon entity. Such 
foreign bodies when ingested find it difficult to maneuver through the GI tract, which makes their 
spontaneous passage almost impossible. Their ingestion is associated with increased risk of impaction, 
perforation and, bleeding. Therefore, early removal of the ingested toothbrush is recommended before 
complications develop. 
Key words: Case Reports; Endoscopy; Foreign Bodies; Psychotic Disorders; Toothbrush 
Cite this article as: Mohindra R, HB N, Mathew R, Ranjan-Rout G, Kaushal K, Aggarwal P. An Unusual Case of Accidental Ingestion of a 
Toothbrush. Adv J Emerg Med. 2020;4(3):e78. 
INTRODUCTION
Foreign body ingestion is a common presenting 
complaint in emergency department (ED), 
especially in the pediatric age group (1). Almost 
80-90% of the ingested foreign bodies are known 
to pass spontaneously through the 
gastrointestinal (GI) tract, without requiring any 
intervention, whereas the rest 10-20% may 
require endoscopic removal and < 1% require 
surgical intervention (2). While ingestion of small 
foreign bodies like coins and button batteries is 
not uncommon, ingestion of long and rigid foreign 
bodies like toothbrush is very rare. Here, we 
describe a 36-year-old man who presented to us 
after accidental ingestion of a toothbrush. 
CASE PRESENTATION 
A 36-year-old man without any known previous 
medical ailments came to the ED with a history of 
accidental swallowing of a toothbrush 12 hours 
back when the patient was cleaning his throat. He 
was complaining of abdominal pain, which was 
constant, dull aching, and localized to the left 
upper quadrant. There was no history of vomiting, 
GI bleeding, constipation, obstipation, or 
abdominal distension. His vital signs were within 
normal limits. Physical examination was mostly 
unremarkable except for mild epigastric 
tenderness. Plain chest and abdominal X-ray did 
 
Figure 1: Axial view of non-contrast CT image of patient’s 
abdomen showing a toothbrush in the stomach 
 
Figure 2: Endoscopic view of toothbrush which was 
grabbed with polypectomy snare 
 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e78 Mohindra et al 
   
 2 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
not reveal the presence of any foreign body. Non-
contrast computed tomography (CT) scan of the 
abdomen was performed, which revealed the 
presence of a toothbrush in the stomach (Figure 
1). There was no sign of bowel perforation like 
discontinuity of bowel wall, presence of 
extraluminal air, and bowel wall thickening on CT 
images.  Upper gastrointestinal endoscopy (UGIE) 
was performed under local anesthesia, which 
showed the toothbrush in the stomach, with its 
head against the pylorus. The toothbrush was 
grabbed using a polypectomy snare and was 
successfully removed (Figure 2). The procedure 
was uneventful. On detailed evaluation, the 
patient was found to have auditory hallucinations, 
persecutory delusions, and had increased religious 
thoughts. Psychiatry consult was sought, and a 
diagnosis of an acute and transient psychotic 
disorder (ATPD) was made. The patient was 
started on antipsychotic Olanzapine 10mg q24h 
and advice to follow up in psychiatry out-patient 
department.  
DISCUSSION 
Usually, most of the ingested foreign bodies 
commonly lodge in the pylorus of the stomach or 
the duodenal C-loop or at the ileocecal valve (3). 
Ingested toothbrushes, too, similarly have been 
reported at various locations in the GI tract like 
parapharyngeal space, esophagus, stomach, ileum, 
and colon causing various complications like, 
rupture of pharyngeal mucosa, intestinal 
perforation, colohepatic fistula with hepatic 
abscess, and even death (4-7). It seems that, the 
first case of successful endoscopic removal of an 
ingested toothbrush was reported in 1983 (8).   
European Society of Gastrointestinal Endoscopy 
(ESGE) clinical guideline for removal of foreign 
body in the upper gastrointestinal tract in adults 
recommends, CT scan as the imaging modality of 
choice in all patients, especially those with 
suspected perforations or other complications 
that may require surgery (9). Furthermore, the 
ESGE recommends emergent therapeutic 
esophagogastroduodenoscopy, preferably within 
2 hours, but at the latest within 6 hours, for 
foreign bodies inducing complete oesophageal 
obstruction and for sharp-pointed objects or 
batteries in the esophagus and urgent therapeutic 
esophagogastroduodenoscopy (within 24) hours 
for other esophageal foreign bodies with 
incomplete obstruction (9).  
For sharp-pointed objects, magnets, batteries and, 
large/long (> 5 - 6 cm) objects in the stomach, 
ESGE recommends urgent therapeutic 
esophagogastroduodenoscopy (within 24 hours). 
For medium-sized (≥2-2.5cm diameter) blunt 
foreign bodies in the stomach non-urgent 
therapeutic esophagogastroduodenoscopy (within 
72 hours) is suggested. It is recommended to use 
the suitable extraction devices according to the 
type and location of the ingested foreign body. If 
foreign bodies cannot be removed, a case-by-case 
approach depending on the size and type of the 
foreign body is suggested (9).  
Toothbrush ingestion has been rarely reported in 
healthy persons (10). Majority of the previously 
reported cases of toothbrush ingestions have been 
in patients with psychiatric illnesses like bulimia 
and schizophrenia. Therefore, a thorough 
evaluation for underlying psychiatric illness is 
advisable in all patients presenting with such 
uncommon ingestions. Though our patient initially 
complained of accidental ingestion of toothbrush, 
however on a thorough evaluation he was found 
to have underlying ATPD.  ATPD has certain key 
features, such as acute onset (less than two 
weeks) and rapidly changing, variable 
polymorphic picture, which is accepted as 
required criteria and stress as an additional 
criterion. Majority of patients will have complete 
recovery in 2-3 months (11). 
CONCLUSIONS 
Ingestion of long and rigid foreign bodies like a 
toothbrush is an uncommon entity. Such foreign 
bodies when ingested find it difficult to maneuver 
through the GI tract, which makes their 
spontaneous passage almost impossible. Their 
ingestion is associated with increased risk of 
impaction, perforation and, bleeding. Therefore, 
early removal of the ingested toothbrush is 
recommended before complications develop. 
ACKNOWLEDGEMENTS 
We would like to thank Department of 
Gastroenterology for providing endoscopy 
support for management of this case. 
AUTHORS’ CONTRIBUTION 
RM wrote the manuscript, NB, KK, RM managed 
the case and acquired images. PA revised the 
manuscript. 
CONFLICT OF INTEREST 
None declared  
FUNDING 
None declared 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e78 Mohindra et al 
   
 3 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
REFERENCES 
1. Shivakumar AM, Naik AS, Prashanth KB, Hongal GF, Chaturvedy G. Foreign bodies in upper digestive 
tract. Indian J Otolaryngol Head Neck Surg. 2006;58(1):63-8. 
2. Smith MT, Wong RKH. Foreign bodies. Gastrointest Endosc Clin N Am. 2007;17(2):361-82. 
3. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al. Guideline for the 
management of ingested foreign bodies. Gastrointest Endosc. 2002;55(7):802-6. 
4. Farahnak MR, Araghi S, Nikakhlagh S, Saki N. Toothbrush: A Report of an Unusual Foreign Body. Iran J 
Otorhinolaryngol. 2015;27(80):247-9. 
5. Tonkic A, Bogdanovic Z, Grandić L. Successful Endoscopic Removal of a Swallowed Toothbrush: Case 
Report. Case Rep Gastroenterol. 2011;5(1):122-4. 
6. Sewpaul A, Shaban F, Venkatasubramaniam AK, Tennant D, Kelly SB. The case of the forgotten 
toothbrush. Int J Surg Case Rep. 2012;3(5):184-5. 
7. Lee MR, Hwang Y, Kim JH. A case of colohepatic penetration by a swallowed toothbrush. World J 
Gastroenterol WJG. 2006;12(15):2464-5. 
8. Ertan A, Kedia SM, Agrawal NM, Akdamar K. Endoscopic removal of a toothbrush. Gastrointest 
Endosc. 1983;29(2):144-5. 
9. Birk M, Bauerfeind P, Deprez PH, Häfner M, Hartmann D, Hassan C, et al. Removal of foreign bodies in 
the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical 
Guideline. Endoscopy. 2016;48(05):489-96. 
10. Kiran S, Gupta D, Sadalage A, Gupte A, Jain A, Shukla A. Swallowed toothbrush: Case series. J Dig 
Endosc. 2016;7(2):77. 
11. Organization WH. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical 
Descriptions and Diagnostic Guidelines. World Health Organization; 1992. Available on: 
https://apps.who.int/iris/handle/10665/37958. Accessed July 28, 2019. 
 


An Unusual Case of Accidental Ingestion of a Toothbrush

Frontiers in Emergency Medicine (E-Journal)

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e78 Mohindra et al     1 Copyright © 2020 Tehran University of Medical Sciences This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).   Case Report DOI: 10.22114/ajem.v0i0.275 An Unusual Case of Accidental Ingestion of a Toothbrush   Ritin Mohindra1, Nayan HB2, Roshan Mathew2*, Gyan Ranjan Rout 3, Kanav Kaushal3, Praveen Aggarwal2  1. Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India. 2. Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India. 3. Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.  *Corresponding author: Roshan Mathew; Email: roshmat15@gmail.com Published online: 2019-10-10 Abstract  Introduction: Foreign body ingestion is a common presenting complaint in the emergency department. While ingestion of small foreign bodies like coins and button batteries is not uncommon, ingestion of long and rigid foreign bodies like toothbrush is very rare. Case presentation: We describe a 36-year-old man who presented to us after accidental ingestion of a toothbrush. The patient underwent urgent endoscopic removal; Psychiatric evaluation revealed an acute and transient psychotic disorder in him.  Conclusion: Ingestion of long and rigid foreign bodies like a toothbrush is an uncommon entity. Such foreign bodies when ingested find it difficult to maneuver through the GI tract, which makes their spontaneous passage almost impossible. Their ingestion is associated with increased risk of impaction, perforation and, bleeding. Therefore, early removal of the ingested toothbrush is recommended before complications develop. Key words: Case Reports; Endoscopy; Foreign Bodies; Psychotic Disorders; Toothbrush Cite this article as: Mohindra R, HB N, Mathew R, Ranjan-Rout G, Kaushal K, Aggarwal P. An Unusual Case of Accidental Ingestion of a Toothbrush. Adv J Emerg Med. 2020;4(3):e78. INTRODUCTIONForeign body ingestion is a common presenting complaint in emergency department (ED), especially in the pediatric age group (1). Almost 80-90% of the ingested foreign bodies are known to pass spontaneously through the gastrointestinal (GI) tract, without requiring any intervention, whereas the rest 10-20% may require endoscopic removal and < 1% require surgical intervention (2). While ingestion of small foreign bodies like coins and button batteries is not uncommon, ingestion of long and rigid foreign bodies like toothbrush is very rare. Here, we describe a 36-year-old man who presented to us after accidental ingestion of a toothbrush. CASE PRESENTATION A 36-year-old man without any known previous medical ailments came to the ED with a history of accidental swallowing of a toothbrush 12 hours back when the patient was cleaning his throat. He was complaining of abdominal pain, which was constant, dull aching, and localized to the left upper quadrant. There was no history of vomiting, GI bleeding, constipation, obstipation, or abdominal distension. His vital signs were within normal limits. Physical examination was mostly unremarkable except for mild epigastric tenderness. Plain chest and abdominal X-ray did  Figure 1: Axial view of non-contrast CT image of patient’s abdomen showing a toothbrush in the stomach  Figure 2: Endoscopic view of toothbrush which was grabbed with polypectomy snare  ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e78 Mohindra et al     2 Copyright © 2020 Tehran University of Medical Sciences This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).   not reveal the presence of any foreign body. Non-contrast computed tomography (CT) scan of the abdomen was performed, which revealed the presence of a toothbrush in the stomach (Figure 1). There was no sign of bowel perforation like discontinuity of bowel wall, presence of extraluminal air, and bowel wall thickening on CT images.  Upper gastrointestinal endoscopy (UGIE) was performed under local anesthesia, which showed the toothbrush in the stomach, with its head against the pylorus. The toothbrush was grabbed using a polypectomy snare and was successfully removed (Figure 2). The procedure was uneventful. On detailed evaluation, the patient was found to have auditory hallucinations, persecutory delusions, and had increased religious thoughts. Psychiatry consult was sought, and a diagnosis of an acute and transient psychotic disorder (ATPD) was made. The patient was started on antipsychotic Olanzapine 10mg q24h and advice to follow up in psychiatry out-patient department.  DISCUSSION Usually, most of the ingested foreign bodies commonly lodge in the pylorus of the stomach or the duodenal C-loop or at the ileocecal valve (3). Ingested toothbrushes, too, similarly have been reported at various locations in the GI tract like parapharyngeal space, esophagus, stomach, ileum, and colon causing various complications like, rupture of pharyngeal mucosa, intestinal perforation, colohepatic fistula with hepatic abscess, and even death (4-7). It seems that, the first case of successful endoscopic removal of an ingested toothbrush was reported in 1983 (8).   European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline for removal of foreign body in the upper gastrointestinal tract in adults recommends, CT scan as the imaging modality of choice in all patients, especially those with suspected perforations or other complications that may require surgery (9). Furthermore, the ESGE recommends emergent therapeutic esophagogastroduodenoscopy, preferably within 2 hours, but at the latest within 6 hours, for foreign bodies inducing complete oesophageal obstruction and for sharp-pointed objects or batteries in the esophagus and urgent therapeutic esophagogastroduodenoscopy (within 24) hours for other esophageal foreign bodies with incomplete obstruction (9).  For sharp-pointed objects, magnets, batteries and, large/long (> 5 - 6 cm) objects in the stomach, ESGE recommends urgent therapeutic esophagogastroduodenoscopy (within 24 hours). For medium-sized (≥2-2.5cm diameter) blunt foreign bodies in the stomach non-urgent therapeutic esophagogastroduodenoscopy (within 72 hours) is suggested. It is recommended to use the suitable extraction devices according to the type and location of the ingested foreign body. If foreign bodies cannot be removed, a case-by-case approach depending on the size and type of the foreign body is suggested (9).  Toothbrush ingestion has been rarely reported in healthy persons (10). Majority of the previously reported cases of toothbrush ingestions have been in patients with psychiatric illnesses like bulimia and schizophrenia. Therefore, a thorough evaluation for underlying psychiatric illness is advisable in all patients presenting with such uncommon ingestions. Though our patient initially complained of accidental ingestion of toothbrush, however on a thorough evaluation he was found to have underlying ATPD.  ATPD has certain key features, such as acute onset (less than two weeks) and rapidly changing, variable polymorphic picture, which is accepted as required criteria and stress as an additional criterion. Majority of patients will have complete recovery in 2-3 months (11). CONCLUSIONS Ingestion of long and rigid foreign bodies like a toothbrush is an uncommon entity. Such foreign bodies when ingested find it difficult to maneuver through the GI tract, which makes their spontaneous passage almost impossible. Their ingestion is associated with increased risk of impaction, perforation and, bleeding. Therefore, early removal of the ingested toothbrush is recommended before complications develop. ACKNOWLEDGEMENTS We would like to thank Department of Gastroenterology for providing endoscopy support for management of this case. AUTHORS’ CONTRIBUTION RM wrote the manuscript, NB, KK, RM managed the case and acquired images. PA revised the manuscript. CONFLICT OF INTEREST None declared  FUNDING None declared ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e78 Mohindra et al     3 Copyright © 2020 Tehran University of Medical Sciences This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).   REFERENCES 1. Shivakumar AM, Naik AS, Prashanth KB, Hongal GF, Chaturvedy G. Foreign bodies in upper digestive tract. Indian J Otolaryngol Head Neck Surg. 2006;58(1):63-8. 2. Smith MT, Wong RKH. Foreign bodies. Gastrointest Endosc Clin N Am. 2007;17(2):361-82. 3. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55(7):802-6. 4. Farahnak MR, Araghi S, Nikakhlagh S, Saki N. Toothbrush: A Report of an Unusual Foreign Body. Iran J Otorhinolaryngol. 2015;27(80):247-9. 5. Tonkic A, Bogdanovic Z, Grandić L. Successful Endoscopic Removal of a Swallowed Toothbrush: Case Report. Case Rep Gastroenterol. 2011;5(1):122-4. 6. Sewpaul A, Shaban F, Venkatasubramaniam AK, Tennant D, Kelly SB. The case of the forgotten toothbrush. Int J Surg Case Rep. 2012;3(5):184-5. 7. Lee MR, Hwang Y, Kim JH. A case of colohepatic penetration by a swallowed toothbrush. World J Gastroenterol WJG. 2006;12(15):2464-5. 8. Ertan A, Kedia SM, Agrawal NM, Akdamar K. Endoscopic removal of a toothbrush. Gastrointest Endosc. 1983;29(2):144-5. 9. Birk M, Bauerfeind P, Deprez PH, Häfner M, Hartmann D, Hassan C, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-96. 10. Kiran S, Gupta D, Sadalage A, Gupte A, Jain A, Shukla A. Swallowed toothbrush: Case series. J Dig Endosc. 2016;7(2):77. 11. Organization WH. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization; 1992. Available on: https://apps.who.int/iris/handle/10665/37958. Accessed July 28, 2019.  

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An Unusual Case of Accidental Ingestion of a Toothbrush

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