A Case of Iatrogenic Foreign Body Ingestion

Abstract

Purpose: Foreign bodies in the esophagus are an indication for urgent upper endoscopy. If left in the esophagus, they can cause ulceration, bleeding, or perforation. A diagnostic approach is to either follow the foreign object for natural passage using serial imaging vs. urgent endoscopic removal, depending upon the physical characteristics of the foreign body. Case: 69 year old male with diabetes, hypertension, and acute on chronic renal failure was admitted to the hospital for syncope. After admission, he had a choking episode and underwent cardiac arrest and resuscitation with intubation. Subsequent CXR reveals two coin shaped opacities in the mid and distal esophagus. He was kept NPO, remained hemodynamically stable without recurrent choking episodes, and a GI consultation was made for removal. Two repeat CXRs showed persistence of two coin-like objects in the esophagus. EGD was performed with the finding of two white chalky pills with identification stamps. One remained in the esophagus and one progressed into the stomach. They were retrieved by Roth Net® and identified as Fosrenol® lanthanum carbonate chewable oral pills. There were no esophageal rings, strictures, stenoses, or mucosal erosions. Discussion: Patients with chronic kidney disease often are on multiple medications including phosphate binders. In this case, the patient was given Fosrenol® tablets uncrushed and unchewed, despite manufacturer's instructions to do so. Lanthanum carbonate is a non-calcium, non-aluminum containing phosphate binder which appears radio-opaque on Xray imaging. It is a rare earth element of atomic number 57 of low aqueous solubility which does not pass easily through the lining of the gastrointestinal tract. There has been only one previous case report of lanthanum carbonate pills being confused with the ingestion of coins, by imaging studies (Singanamala S, et al., 2008). Other medications which can easily be misidentified as a foreign object on imaging studies include: calcium carbonate, iron sulfate, salt tablets, iodide, zinc, acetazolamide, and TCAs. It is important to consider radio-opaque pill ingestion as a culprit for incidental findings of coin-like objects in the esophagus.