Abstract | December 19, 2022

Recurrent Abdominal Pain of an Unexpected Source: A Case Presentation

Presenting Author: Amy Morrison, BS, Medical Student, 4th Year, University of Central Florida, College of Medicine, Orlando, Florida

Coauthors: Amy Morrison, BS, Medical Student, 4th Year, University of Central Florida College of Medicine, Orlando, FL; Angie El-Said, BS, Medical Student, 4th Year, University of Central Florida College of Medicine, Orlando, FL; Peter Dominguez, BS, Medical Student, 4th Year, University of Central Florida College of Medicine, Orlando, FL; Patricia Portmann, BS, Medical Student, 4th Year, University of Central Florida College of Medicine, Orlando, FL; Jonathan B. Vazquez, MD, Pathologist, Department of Pathology, Orlando VA Medical Center, Orlando, FL; and Minh Q. Ho, DO, Infectious Disease, Orlando VA Medical Center, Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL.

Learning Objectives

  1. Consider foreign body ingestion as part of the differential diagnosis in patients presenting with recurrent and intractable abdominal pain, ileitis, or acute abdomen.
  2. Consider earlier surgical intervention in patients with waxing and waning improvement of abdominal pain and imaging in a similar abdominal area.
  3. Further question about previous ingestion if there is high clinical suspicion of ileitis secondary to a foreign body.

Introduction: Ingesting a foreign body may lead to several potentially lethal gastrointestinal complications. Unfortunately, this diagnosis is often not considered due to variable onset of symptoms and due to patients not recalling ingestion. This case report aims to present a case of recurrent abdominal pain and ileitis of four months duration secondary to ingestion of a toothpick and to urge providers to consider foreign bodies as a possible etiology for recurrent ileitis refractory to antibiotic treatment.

 

Case Presentation: A 74-year-old male was admitted to the hospital in January of 2022 with intractable bilateral lower abdominal pain, characterized as cramping, constant, and waxing and waning in severity. This was his third hospital admission for abdominal pain, the first of which occurred four months prior in October 2021. Each admission, his pain had been treated with intravenous antibiotics. His vital signs were within normal limits. Physical examination was significant for diffuse tenderness to palpation in the lower bilateral abdominal quadrants without peritoneal signs. Laboratory studies revealed a normal leukocyte count. A CT scan showed a likely source of his persistent pain: a small fluid collection with concomitant inflammation in the central mesentery and ileum concerning for perforation. Notably, this fluid collection had been present in prior CT scans but was managed nonoperatively. The patient was started on intravenous piperacillin/tazobactam with plans for diagnostic laparotomy.

 

Final Diagnosis: Diagnostic laparotomy with small bowel resection and primary anastomosis was performed. The surgical team discovered the source of his abdominal pain: an intact toothpick, perforating the ileum, walled off by omental, colon, and mesentery adhesions.

 

Management/Outcome/Follow Up: This patient’s intractable abdominal pain and ileitis of four months duration was secondary to ingestion of a sharp foreign body: a toothpick. His recovery was complicated by a superficial wound infection noted on postoperative day 8. He recovered bowel function appropriately and his diet was advanced as tolerated. He was discharged with close follow-up in the surgery and wound care clinics.

 

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