An Unusual Presentation of a Retained Esophageal Foreign Body

Abstract

Case ReportsAn Unusual Presentation of a Retained Esophageal Foreign Body Akhter Nawaz, FRCSI Alic Jacobsz, FRCS Joseph Herticant, and MD Ahmed H. Al-SalemFRCS Akhter Nawaz Address reprint requests and correspondence to Dr. Nawaz: Department of Surgery, Tawam Hospital, P.O. Box 1525, Al-Ain, Abu Dhabi, United Arab Emirates. From the Departments of Surgery, Tawam Hospital, Al-Ain, Abu Dhabi, United Arab Emirates. Search for more papers by this author , Alic Jacobsz From the Departments of Surgery, Tawam Hospital, Al-Ain, Abu Dhabi, United Arab Emirates. Search for more papers by this author , Joseph Herticant From the Pediatrics, Tawam Hospital, Al-Ain, Abu Dhabi, United Arab Emirates. Search for more papers by this author , and Ahmed H. Al-Salem From the Departments of Surgery, Tawam Hospital, Al-Ain, Abu Dhabi, United Arab Emirates. Search for more papers by this author Published Online:1 Mar 1998https://doi.org/10.5144/0256-4947.1998.164SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionA Nawaz, A Jacobsz, J Herticant, AH. Al-Salem, An Unusual Presentation of a Retained Esophageal Foreign Body. 1998; 18(2): 164-166Foreign body ingestion is a common problem in children, but fortunately the majority of swallowed foreign bodies transverse the gastrointestinal tract without any adverse effects.1–3 Retained foreign bodies in the esophagus, on the other hand, can produce serious complications.4 We report a child with an unusual presentation due to a retained esophageal foreign body. The hazards of the impact of esophageal foreign bodies, diagnostic investigations and delayed referrals are highlighted.CASE REPORTA 2½-year-old boy was referred to our hospital with a history of dysphagia for solids for 18 months and stridor for one week. This child was thriving and eating well until the age of one year, when the parents noticed that he could not swallow solid foods. Prior to presentation to our hospital, he had had esophagoscopy for removal of a coin, but in spite of this his dysphagia had not been relieved. Barium swallow (Figure 1) showed a 3 cm long narrowing of the proximal third of the esophagus. The esophagus above the stenosis showed dilatation and diverticulum formation. The trachea appeared compressed and narrowed. Spiral CT scan with IV contrast was done on 8 mm axial slides. This showed air collection connected with the anterior esophageal wall, which caused displacement and narrowing of the trachea. Further down, there was evidence of a low-density diffusely enhancing soft tissue lesion encircling the trachea and esophagus, causing compression of the posterior tracheal wall and narrowing of the tracheal lumen. No foreign body could be demonstrated and the findings were attributed to mediastinitis caused by perforation of the esophagus secondary to removal of the coin. Flexible endoscopy revealed only esophageal stricture with prestenotic dilation and diverticulum formation. Balloon esophageal dilation of the stricture was done. This resulted in temporary relief. The patient was re-admitted three weeks later with dysphagia and stridor. A repeat spiral CT scan with 3 mm cuts revealed a transversely oriented circular foreign body, 2 cm in diameter, impacted at the level of manubrium sternum and slightly above the carina (Figure 2). It was partially located in the esophageal lumen, but the rest of it was covered by soft tissues. The proximal esophagus showed pouch-like dilation and a pseudodiverticulum formation with soft tissue thickening in the mediastinum. This was confirmed by MRI of the mediastinum which, in addition to the foreign body, clearly showed a granulomatous mass extending longitudinally from the level of the esophageal pouch down to 4 cm below the carina, displacing the trachea anteriorly, which was also compressed and flattened.Figure 1. Barium swallow showing esophageal stricture and proximal dilation with pseudodiverticulum formation.Download FigureFigure 2. CT scan showing the swallowed foreign body (→) embedded in a mass of a soft tissue and compressing the trachea.Download FigureThe patient was operated on via a cervical incision extending from the manubrium sternum upwards along the anterior border of the sternocleidomastoid for about 4 cm. The trachea and esophagus were defined. The posterior mediastinum was entered and the foreign body was found and removed. It was embedded in a mass of inflammatory tissue posterior to the esophagus. Tough fibrous tissue was also encountered. This was dissected and the trachea as well as the esophagus and left main bronchus were freed. The right main bronchus origin was also freed. A small bronchoscope was passed through the mouth into the esophagus just before closure of the wound. This passed easily through the esophagus and into the stomach. No evidence of esophageal laceration was demonstrated. The wound was closed and a port-a-vac drain was left inside. After the operation, the patient was ventilated for two days. The removed foreign body was a disc of plastic material with a hole in the periphery. This was shown to the parents, who confirmed it to be a button with a shiny coating material that is worn by women to decorate dresses. The removed foreign body was transparent, as the coating material had already dissolved.Postoperatively, the patient did well and was feeding via a nasogastric tube. An esophagogram done on the 5th postoperative day showed a small esophageal leak. This was treated conservatively and the child was allowed to have oral feeds on the 17th postoperative day. A repeat esophagogram on the 35th postoperative day showed a normal intact esophagus. The patient is now swallowing normally and gaining weight.DISCUSSIONForeign body ingestion is common in children between the ages of six months and three years.1 A large variety of foreign bodies are swallowed by children, but coins are the most common.4 Fortunately, 80% to 90% of swallowed foreign bodies will pass spontaneously and in many instances may go unrecognized without the parents of the victims becoming aware of them. About 10% to 20% of swallowed foreign bodies will have to be removed endoscopically, and fewer than 1% will need to be removed surgically.1–3There is a definite predilection for esophageal foreign bodies to become stuck at the level of the cricopharyngeous and just below. Not uncommonly, retained esophageal foreign bodies in children are associated with a preexisting stricture which is mostly congenital.5 Retained esophageal foreign bodies should be removed as soon as possible endoscopically, by way of either a rigid or flexible endoscope. This is to lessen the risk of complications. Retainment and impaction of esophageal foreign bodies cause esophageal wall necrosis and perforation. The risk of esophageal perforation is higher with sharp objects. Esophageal perforation secondary to foreign bodies may be complicated further by the development of acquired trachea-esophageal fistula,6 as well as aorto-esophageal fistula, which may be fatal.5,7Our patient had a coin sitting above a stricture removed from the esophagus. This stricture was acquired secondary to the first swallowed foreign body, which was radiolucent. This stricture was treated by balloon esophageal dilation with only temporary relief. The possibility of a swallowed second foreign body must always be borne in mind.4 This is especially so in the presence of an esophageal stricture. Had the parents of our patient been aware of the ingestion of the original foreign body, immediate endoscopy would have prevented these complications. It is of vital importance, therefore, that patients with swallowed esophageal foreign bodies be referred early for immediate evaluation and treatment. The original foreign body in our patient was non-radio-opaque and so it was difficult to visualize it radiologically. It was only after a repeat spiral CT scan with 3 mm cuts that the foreign body was shown. Thin contrast studies have been advocated to visualize non-radio-opaque foreign bodies.4 Our patient presented late when there was already esophageal perforation with protrusion of the foreign body outside the esophagus, and so it was not visualized on barium swallow, and only secondary esophageal stricture and proximal diverticulum formation was seen. In a situation like ours, when there is a possibility of a swallowed non-radio-opaque foreign body, especially thin ones that cannot be visualized by barium swallow, we advocate performing a spiral CT scan with thin 3 mm cuts.The swallowed foreign body in our patient perforated the esophageal wall and protruded into the mediastinum, leading to esophageal stricture, with prestenotic dilation and diverticulum formation. There was, in addition, an intense inflammatory reaction to this type of foreign body in the mediastinum that led to tracheobronchial narrowing with respiratory difficulty. We think that this intense inflammatory reaction was probably secondary to the coating material of this foreign body, although the nature of this coating material could not be determined. Such types of objects are commonly used in the Gulf countries by women to decorate dresses. Physicians caring for children demonstrating these symptoms should be aware of this possibility, and certainly such types of foreign bodies should be kept out of the reach of children.ARTICLE REFERENCES:1. Webb WA. "Management of foreign bodies of the upper gastrointestinal tract" . Gastroenterology. 1988; 94: 204–16. Google Scholar2. Henderson CT, Engel J, Schlesinger P. "Foreign body ingestion: review and suggested guidelines for management" . Endoscopy. 1987; 19: 69–71. Google Scholar3. Nandi P, Ong GB. "Foreign body in the esophagus: review of 2, 394 cases" . Br J Surg. 1978; 65: 5–9. Google Scholar4. Webb WA. "Management of foreign bodies of the upper gastrointestinal tract: update" . Gastrointest Endosc. 1995; 41: 39–51. Google Scholar5. Shankar BR, Yachha SK, Sbarma BC, Singh B, Mahant TS, Kapoor VK. "Retained esophageal foreign bodies in children" . Pediatr Surg Int. 1996; 11: 544–6. Google Scholar6. Koltai JL, Scholtz J. "Acquired tracheoesophageal fistula in childhood" . Pediatr Surg Int. 1995; 10: 46–7. Google Scholar7. Wu MH, Lai WW. "Aortoesophageal fistula induced by foreign bodies" . Ann Thorac Surg. 1992; 54: 155–6. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 18, Issue 2March 1998 Metrics History Received6 September 1997Accepted17 December 1997Published online1 March 1998 InformationCopyright © 1998, Annals of Saudi MedicinePDF download