Dr. Alejandro Heffess first encountered the toothbrush mystery back in around 2003, when he was a radiology resident at Mount Auburn Hospital in Cambridge, Mass.
The X-ray order on the 19-year-old woman said, “ingested foreign body.” In the image of her abdomen, he observed a set of little metallic densities arranged in several rows, in a pattern almost like the dots on a domino.
He called over to the Emergency Department to ask what exactly she had ingested.
“A toothbrush,” he was told.
A toothbrush? The patient was reportedly a healthy young woman with no history of mental illness. So how …? Well, fluke accidents happen, he figured.
Then, about a year later, he saw it again. “You see that once, it’s an isolated, sporadic event,” said Dr. Heffess, who is now a radiologist and director of ultrasound services at Mount Auburn. “You see it twice and all of a sudden it’s a pattern — that’s what spurred my curiosity: ‘This is something people do? Under what circumstances and why?’”
The second patient was another young woman, this one recently married, and she implored the medical staff not to tell anyone in her family how “stupid” she had been. “Just take care of this,” she begged. (In many cases, big swallowed objects can be removed by a gastroenterologist using an endoscopy tube inserted down the throat. Sometimes, surgery may be needed.)
Puzzling over the two toothbrushes, Dr. Heffess mentioned the pair of cases to his wife, Rebecca Weinstock, a social worker. He remembers the conversation as going something like this:
Alex: “This is really confusing to me. I’ve just seen a second case of a young woman swallowing a toothbrush while brushing her teeth. What could that be?”
Rebecca, without a moment’s hesitation: “No one brushing their teeth could accidentally swallow a toothbrush. These women must be bulimic, of course.”
She was right — the women did indeed turn out to have bulimia; they apparently had accidentally swallowed their toothbrushes while using them to trigger a gag reflex to induce a “purge.”
And that astute diagnosis was the genesis of a full-fledged academic paper published in last month’s American Journal of Roentgenology: “Imaging Findings In Eating Disorders.”
In it, Dr. Heffess and his co-authors lay out an array of ways that imaging — X-rays, CT scans, MRI, and more — can alert radiologists to signs of eating disorders or their complications. The radiologist, whose job it is to interpret medical imaging, then reports these findings back to the doctor who ordered the scan and is treating the patient. The imaging findings can be especially helpful, the authors point out, because patients often keep their eating disorders secret.
People with bulimia, in particular, may keep their binging and purging secret because they can; they don’t tend to become rail-thin like anorexics.
Their silence may also be “the secrecy of shame,” said Dr. Katy Aisenberg, an eating disorders specialist in Cambridge. Bulimia tends to involve a sense of being out of control, she said, of being unable to discipline an overactive appetite.
On the toothbrush cases, the paper says:
The presence of an unusual foreign body in the esophagus or stomach on radiographs should raise suspicion for an eating disorder. Patients with eating disorders may use objects to induce vomiting and then accidentally ingest them. Although any object may be used, the toothbrush seems to be used frequently, likely because of its presence in the bathroom, where self-induced vomiting most often occurs.
…Although this behavior can be seen in other mental illnesses, it may be the first clue to the diagnosis of an eating disorder and is one of the easiest for the radiologist to recognize. Recognition of this finding and its immediate communication to the referring physician is important, because the management of ingested foreign bodies includes removal via endoscopy or laparotomy to avoid pressure necrosis or bowel perforation.
Patients may not want to admit to eating disorders, but, Dr. Heffess says, radiologists routinely look “under the hood” of patients’ bodies, and are thus in a good position to pick up signs of the problem.
Ingested objects and other signs of bulimia or anorexia tend to be most familiar to psychiatrists, and also to the surgeons and gastroenterology specialists who actually remove the objects. But eating disorders are not usually on the radar screens of radiologists, unless they are specifically told that the patient has a history of one.
After his wife made the diagnosis, Dr. Heffess began gathering cases of patients with eating disorders, and looking for relevant imaging abnormalities. Dr. Jessica Kraeft, his resident and now co-author, helped propel the project to fruition as a journal paper. It notes a wide variety of signs and complications of eating disorders that imaging can detect:
• If a chest X-ray reveals that a patient has very little muscle and fat, and a very small heart, that could be a sign of poor nutrition and anorexia.
• If a radiologist sees debris in the airways and lungs, it could be pneumonia from aspiration — food may have been breathed in during vomiting as part of bulimia or anorexia.
• Very low bone density, particularly in adolescents whose bone mass should be at its peak, can be a sign of anorexia.
• Rectal prolapse, in which part of the rectal wall slides or stretches out of place, can be caused by laxative abuse and other forms of purging.
• In young, otherwise healthy people, poor teeth can be a sign of an eating disorder, as can brain atrophy or shrinkage.
The paper includes many other imaging findings, all aimed at alerting radiologists to possible — emphasis on the possible — signs of eating disorders. But what about the rest of us laypeople? What if a loved one of ours needs imaging for some reason and the scans happen to turn up a smaller-than-expected brain or lung debris?
Many of these imaging findings are nonspecific, meaning they can be seen in a variety of conditions. So it depends, Dr. Heffess said. “If my kid is 19 and she gets a head CT for trauma, and they happen to say there’s more brain tissue loss than expected for her age, it could be many things. For the doctor to say, ‘I wonder if your daughter or son has an eating disorder,’ would be a stretch.”
“On the other hand, if your child is found to have swallowed a foreign body, maybe the parent, instead of saying, ‘What the hell happened?’ could say, ‘Is something wrong? Is there something you want to talk about?’ We see unusual occurrences and we might dismiss them as ‘that weird thing that happened,’ but with a little curiosity, you might find much more to it than you expect.”
The third time Dr. Heffess saw a swallowed toothbrush on imaging, he immediately called the Emergency Department physician and said, “The presence of an ingested toothbrush is a sign of an eating disorder. Is this a known illness in your patient?’”
No, he was told.
“Then,” he said, “this question must be raised.”