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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 119-121

Interesting case of esophageal perforation due to foreign body


1 Department of General and Gastro surgery, Billroth Hospital, Chennai, Tamil Nadu, India
2 Department of Surgical Gastroenterology, Royapettah Government Hospital, Chennai, Tamil Nadu, India
3 Department of Cardiothoracic Surgery, Madras Medical College, Chennai, Tamil Nadu, India
4 Department of Respiratory Medicine, Billroth Hospital, Chennai, Tamil Nadu, India
5 Department of Cardiology, Stanley Medical College, Chennai, Tamil Nadu, India
6 Department of Anesthesia and Critical Care, Billroth Hospital, Chennai, Tamil Nadu, India

Date of Submission04-Sep-2021
Date of Decision22-Oct-2021
Date of Acceptance18-Nov-2021
Date of Web Publication12-May-2022

Correspondence Address:
Mohan Venkataraman
Department of Respiratory Medicine, Billroth Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_37_21

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  Abstract 


A 75 year old gentleman, who is a chronic heavy smoker and edentulous person who used to swallow his food rather than proper mastication, presented with chest pain and dysphagia. CT scan revealed foreign body penetrating the oesophagus and invading the mediastinum leading to a mediastinal collection. Upper gastrointestinal endoscopy to remove the foreign body was not successful, and hence open surgery was done by specialist in thoracic and surgical Gastroenterology. The foreign body was removed successfully and treated with appropriate antibiotics. Patient was discharged home as per plan and followed up in out patient clinic. He has been keeping well.

Keywords: Foreign body, meadiastinitis, oesophagus


How to cite this article:
Bhawarlal PK, Murugaiyan G, Raj SK, Venkataraman M, Thirukonda J, Ravichandran P. Interesting case of esophageal perforation due to foreign body. J Assoc Pulmonologist Tamilnadu 2021;4:119-21

How to cite this URL:
Bhawarlal PK, Murugaiyan G, Raj SK, Venkataraman M, Thirukonda J, Ravichandran P. Interesting case of esophageal perforation due to foreign body. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 May 16];4:119-21. Available from: http://www.japt.com/text.asp?2021/4/3/119/345081




  Introduction Top


We are presenting a case of foreign body ingestion resulting in perforation of the esophagus. The case was a therapeutic management challenge, as the foreign body, which was a mutton bone, got stuck in the esophagus leading to perforation. The foreign body further invaded the mediastinum causing pneumomediastinum and infective collection.


  Case Report Top


A 75-old-year gentleman presented to us with complaints of pain in the upper chest and dysphagia for 3 days. He could relate the symptoms to consumption of a mutton dish made at home [Figure 1]. The patient had no difficulty in breathing. He had a 55 pack-year history of smoking. He was not known to have diabetes mellitus, hypertension, or ischemic heart disease.
Figure 1: Mutton bone which was extracted

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The patient first went to a tertiary care government hospital, where he was admitted, but was not clear what happened there, later he signed himself out and went to a corporate hospital for a day and then came here for further management.

On examination, the patient was conscious, oriented, and afebrile and was in discomfort. His vitals were stable, pulse: 82/min, BP: 120/80 mmHg, and SpO2: 97% on room air. On examination of the chest, palpable crepitus on the anterior chest wall indicating surgical emphysema. Cardiovascular system – S1 S2 heard, respiratory system-bilateral air entry present, normal vesicular breath sounds, per abdomen-soft, central nervous system – no focal neurological deficit

He was evaluated in the emergency room and found to have a foreign-body bone piece in the esophagus with perforation and mediastinitis, on computed tomography scan [Figure 2].[1] It was actually impacted in the retrosternal part of upper thoracic esophagus edging to perforate the trachea.[2]
Figure 2: Computed tomography showing impacted foreign body

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Pulmonary function test could not be performed because of his condition.

Echo showed calcific aortic and mitral valve, normal left ventricular systolic function.[3]

Endoscopic removal of foreign body was attempted but failed as it was firmly stuck to the esophagus.[4],[5],[6]

Emergency surgery was planned in view of collection in mediastinum and impending septicemia.[7]

Cardiologist and pulmonologist opinions were obtained and advice followed.

Through neck incision, the esophagus was incised, left lateral incision made in the neck and extended till sternum.[8] The thyroid gland and carotids were mobilized. Perforation noted at the retrosternal part of upper thoracic esophagus due to a mutton bone piece impaction.[9] It was retrieved along with frank pus and retained food material following which thorough lavage was given and esophagus repaired. To start enteral nutrition immediately, a feeding jejunostomy was performed.

Postoperatively patient recovered from mediastinitis and discharged on 5th postoperative day.


  Discussion Top


Esophageal foreign bodies are not a rare phenomenon.

In general, there are two kinds of materials that could be impacted in the esophagus, which are foreign bodies and food particles/bolus. In children, most commonly ingested ones are small toys or coins and in adults any large food particles. Preexisting physical and mental conditions can be a risk factor.

Impacted foreign bodies could cause various complications such as ulcer, inflammation, infection, and perforation. Perforation of esophagus could lead to mediastinitis, empyema, abscess, and fistula. Generally, the standard practice is to remove the foreign-body endoscopically. However, in this case, foreign body was firmly impacted in the esophagus. Hence removing endoscopically will cause large tear/perforation, and hence the procedure was deferred.

This elderly gentleman had a 55 pack year of smoking, with suspected impaired lung function status. When these patients present to the hospital, it would be ideal to handle them quickly, as delay means more complications. The safest option was to do an upper gastrointestinal endoscopy and remove the foreign body. Due to technical difficulty, an open surgery option had to be considered.

A left lateral incision made in neck, extended till sternum. Thyroid gland mobilized medially, carotid artery mobilized laterally, and esophagus mobilized.

Perforation in esophagus with abscess (around 100 ml) noted. Impacted foreign-body bone piece noted at perforation site.

Thorough lavage done, abscess drained, and pus sent for culture and sensitivity. Foreign body retrieved after making a 3 cm vertical incision over esophagus at C5-C7 level. Unhealthy slough was removed and local wash was given. Drain was placed in appropriate position and wound was closed in layers. Feeding jejunostomy was done to start immediate enteral nutrition. Patient was extubated on table. Postprocedure, patient recovered well and discharged on 5th postoperative day. On follow-up visit, a leak test was done, and esophageal integrity was found to be normal. Hence, feeding jejunostomy was removed, and the patient started on liquids followed by normal diet gradually.

Had he consulted a dentist on time, he could have escaped from this agony, as he was an edentulous person who used to swallow rather than chew food.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Triadafilopoulos G, Roorda A, Akiyama J. Update on foreign bodies in the esophagus: diagnosis and management. Curr Gastroenterol Rep 2013;15:317. [PubMed]  Back to cited text no. 1
    
2.
Marco De Lucas E, Sadaba P, Lastra Garcia-Baron P, Ruiz-Delgado ML, Sánchez FG, Ortiz A, et al. Value of helical computed tomography in the management of upper esophageal foreign bodies. Acta Radiol 2004;45:369–74. [PubMed]  Back to cited text no. 2
    
3.
Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr 2001;160:468-72. [PubMed]  Back to cited text no. 3
    
4.
Bekkerman M, Sachdev AH, Andrade J, Twersky Y, Iqbal S. Endoscopic Management of Foreign Bodies in the Gastrointestinal Tract: A Review of the Literature. Gastroenterol Res Pract 2016;2016:8520767. [PubMed]  Back to cited text no. 4
    
5.
Ginsberg G.G. Management of ingested foreign bodies and food bolus impactions, Gastrointest Endosc 1995;41:33-8.  Back to cited text no. 5
    
6.
Vicari JJ, Johanson JF, Frakes JT. Outcomes of acute esophageal food impaction: Success of the push technique. Gastrointest Endosc 2001;53:178–81. [PubMed].  Back to cited text no. 6
    
7.
Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55:802-6. [PubMed].  Back to cited text no. 7
    
8.
Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg 1978;65:5-9.  Back to cited text no. 8
    
9.
Chauvin, A, Viala J, Marteau P, Hermann P, Dray X. Management and endoscopic techniques for digestive foreign body and food bolus impaction. Dig Liver Dis 2013;45:529-42.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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