A 40-Year-Old Man With 2-Year Chronic Epigastric Pain From a Retained 18-cm Toothbrush: Endoscopic Management and Clinical Decision-Making

Introduction

Foreign body ingestion is overwhelmingly common in pediatric patients, while adult non-food object ingestion is far less frequent, typically linked to food bolus impaction, psychiatric illness, self-harm, or alcohol intoxication [1,2]. Small blunt foreign bodies often pass spontaneously, but long rigid objects (>6 cm) rarely traverse the pylorus or duodenal sweep, requiring intervention to prevent pressure necrosis, perforation, or fistula formation [1,3].

Adult toothbrush ingestion is very rare, with the literature limited to isolated case reports [4–6]. Diagnosis is frequently delayed due to intoxication-related amnesia or patient embarrassment [2,5]. This report describes the endoscopic management of a toothbrush retained for 20 years, highlighting clinical decision-making when imaging and physical examination findings conflict.

Case Report

A 40-year-old man presented to our gastroenterology service with 2 years of persistent intermittent epigastric pain. He was afebrile and hemodynamically stable; abdominal examination was unremarkable, with no tenderness, palpable mass, or abnormal routine laboratory test results.

Repeated targeted history-taking revealed the patient had swallowed a standard 18-cm household toothbrush 20 years prior, during heavy alcohol consumption, after a bet with peers. He denied any psychiatric history, but reported regular heavy alcohol use with impaired behavioral control when intoxicated.

Outside contrast-enhanced abdominal CT identified a linear foreign body spanning the gastric antrum to the descending duodenum, with suspected adhesion of the duodenal bulb to the liver capsule and sinus tract formation (Figure 1). Because the CT findings appeared more severe than the clinical presentation, we initially proceeded with diagnostic upper endoscopy to further assess the extent of injury.

Endoscopy confirmed the brush head in the gastric antrum, with the handle extending into the descending duodenum. The toothbrush was freely mobile, with intact surrounding mucosa and no evidence of perforation, sinus tract, or fistula (Figure 2A–2C). After discussion with the patient’s family, the foreign body was removed intact via polypectomy snare in a single pass. Repeat duodenal inspection after extraction showed no mucosal injury or residual sinus tract (Figure 2C–2F). The patient’s pain resolved completely within hours after the procedure. Follow-up CT 3 days later showed resolution of duodenal inflammatory changes (Figure 3), and he remained asymptomatic at 6-week follow-up.

Discussion

This case shows that cross-sectional imaging can overestimate the extent of local injury in cases of retained upper gastrointestinal foreign bodies, and that endoscopy can be both diagnostic and therapeutic. In our patient, an outside CT raised concern for a duodenal-hepatic fistula, but endoscopy showed a mobile toothbrush and intact surrounding mucosa without a visible sinus tract. The CT appearance may therefore have reflected chronic local inflammatory apposition rather than a true fistulous tract. This distinction enabled minimally invasive management and avoided unnecessary surgery.

The 20-year retention of an 18-cm rigid toothbrush is unusual. Compared with previously reported toothbrush ingestions that presented acutely or with severe complications such as hepatic abscess, our patient had a longer retention time and a relatively indolent clinical course [4–6]. Current European Society of Gastrointestinal Endoscopy guidelines recommend urgent endoscopic removal for long rigid foreign bodies, as spontaneous passage is extremely rare [3]. One possible explanation for the prolonged retention is that the toothbrush remained in a stable trans-pyloric position, causing localized chronic inflammation rather than acute perforation. This may also help explain the intermittent nature of the patient’s symptoms.

This case also underscores the importance of repeated targeted history-taking for unexplained chronic abdominal pain, as patients often omit reporting remote ingestion events [2,5]. Finally, endoscopy served dual diagnostic and therapeutic roles, confirming the extent of injury and enabling safe foreign body retrieval even when imaging suggested severe transmural damage.

Conclusions

Retained long rigid gastrointestinal foreign bodies should be considered in the differential diagnosis of chronic unexplained epigastric pain. Endoscopic evaluation is critical for clarifying misleading imaging and enabling safe, minimally invasive management.