Needle in a Radiologic Haystack: A Report of Duodenal Toothpick Perforation With Negative X-ray and CT Imaging

Foreign body ingestions are a common presentation in the emergency department. Many of these involve sharp or pointed objects, which may be challenging to detect when made of radiolucent material such as wood. While computed tomography (CT) increases sensitivity, perforation and mucosal injury are often diagnosed late because of false-negative scans. We report the rare case of duodenal toothpick perforation with negative radiographic imaging. A 25-year-old male presented to urgent care after suspected accidental ingestion of a toothpick. The patient had no symptoms and no recollection of toothpick ingestion. After a normal X-ray, he was referred to the emergency department, where CT imaging of the neck, chest, and abdomen did not reveal any foreign body or secondary inflammatory changes. Gastroenterology was consulted and performed an endoscopy, identifying a 4-5 cm wooden toothpick embedded in and perforating the second portion of the duodenum. The foreign body was removed without complications. This case highlights the importance of high clinical suspicion when encountering asymptomatic patients with potential foreign body ingestion of sharp radiolucent objects, even in the absence of radiographic or laboratory evidence of perforation. Endoscopic evaluation in these patients may be warranted to prevent delayed presentation and complications.