The endoscopic removal of foreign bodies, including toothbrushes, is a significant clinical challenge. Ingestion of foreign bodies can lead to a variety of complications [1]. About 1500 deaths annually in the United States are attributed to foreign body ingestion, although overall mortality rates are low overall [2]. Most foreign bodies (80%–90%) pass spontaneously. However, approximately 10% to 20% of cases of foreign body ingestion require endoscopic removal, while less than 1% require surgery for foreign body extraction or to treat complications [3]. Although many foreign bodies are easily removable, certain items such as magnets, blades, barbs, and unusually shaped objects such as toothbrushes present significant challenges [3]. Toothbrushes have the potential to cause complications including pressure ulcers and perforations [4]. We report a case of endoscopic removal of multiple toothbrushes.

A 26-year-old woman with a documented history of schizophrenia was brought to the emergency room after ingesting toothbrush. The patient had a history of intentional ingestion of a foreign body. Upon presentation, the patient was asymptomatic. The patient reported that she had ingested multiple toothbrushes the day prior to her visit. Physical examination revealed normal vital signs and a soft abdomen without any evidence of obstruction or peritoneal irritation. Abdominal radiography revealed multiple linear outlines with radiopaque portions. Subsequent computed tomography confirmed the presence of multiple toothbrushes within the stomach and duodenum (Fig. 1). The results of blood tests were unremarkable. An emergent, non-sedated endoscopy was performed, which revealed the presence of eight toothbrushes, approximately 185 mm in length, within the stomach. Five toothbrushes were embedded within the greater curvature of the stomach, and the other three extended into the duodenal bulb (Fig. 2A). A snare was used to remove each toothbrush individually (Fig. 2B). During the procedure, a short-segment hiatal hernia was observed. The endoscopic snare was maneuvered so that one end of the toothbrush handle, forming a V-shape, was positioned within the hernia to facilitate its passage through the esophagus. Overtube placement was attempted to facilitate passage through the upper esophageal sphincter; however, the internal diameter of the overtube was smaller than that of a toothbrush. Therefore, the patient was instructed to be nauseated to facilitate passage. Due to the length of the toothbrushes, hyperextension of the patient’s neck was necessary to facilitate their removal. This process was repeated with the patient’s cooperation, and the eight toothbrushes were successfully removed within approximately 40 minutes (Fig. 2C). Postprocedural endoscopy did not reveal any significant abnormalities. Follow-up radiographic examinations did not show any significant findings, and the patient was able to start oral intake the following day. As the patient remained asymptomatic, she was discharged after consultation with a psychiatrist.

Foreign body ingestion is a common emergency, which often requires prompt medical intervention. This case involved the ingestion of multiple toothbrushes, which is unusual and presents unique challenges owing to the size, shape, and potential for complications. Toothbrushes are typically not designed to pass through the gastrointestinal tract. Foreign bodies longer than 6 cm cannot overcome the pylorus and superior duodenal angle [5], and foreign bodies larger than 4 cm may not pass the ileocecal valve [6]. Nevertheless, a toothbrush may travel to the colon in a few cases [7]. Toothbrushes can cause significant complications, such as perforation, obstruction, and pressure-ulcer [5]. Endoscopic removal of foreign bodies is widely regarded as a minimally invasive and effective approach, though the endoscopic retrieval of toothbrushes is particularly challenging due to their length and rigidity.[8].

Passing through the gastroesophageal junction is a challenging task. In this case, the short segmental hiatal hernia made it relatively easy for the tip to enter the esophagus. Another difficulty was passing through the upper esophageal sphincter. A previous report of toothbrush removal using an overtube has been published [8]. However, it was unsuccessful in this case due to the large size of the toothbrush. Therefore, removal of the toothbrush by inducing nausea with the patient’s cooperation and timely retraction of the endoscope was effective. Finally, removing it from the oral cavity was another difficult process, and again with the patient’s cooperation, we were able to pass it by hyperextension of the neck, similar to a tracheal intubation position [9].

However, it is important to note that endoscopic removal is not always the only viable treatment. Surgical intervention may be necessary in situations involving complications, such as perforation, obstruction, or failure of endoscopic efforts. According to guidelines, retrieval devices, including snares, baskets, and overtubes, should be tailored to the characteristics of both the foreign body and the patient’s condition [3,5].

This case is notable for the non-sedated endoscopic removal of multiple toothbrushes, a scenario not commonly reported in literature. This shows that even complex foreign body ingestion can be managed safely and effectively using endoscopy without surgery. To our knowledge, this is the first reported case involving endoscopic removal of more than four toothbrushes at once in the English literature, highlighting the importance of customized approaches in the management of unusual foreign body ingestions [10].