On Razorʼs Edge: (S)Hell of a Mussell Impaction With Upper Gastrointestinal Bleeding

Abstract

Esophageal seafood shell impactions have been reported to cause erosions, tears, perforations and fistulae due to sharp broken edges. Severe upper gastrointestinal hemorrhage as an initial presentation can very rarely occur due to tears and lacerations by razor sharp edges, particularly if lodged for prolonged period due to esophageal peristalsis. They require early recognition and removal, which may be very difficult. We report a rare case of such a challenging broken mussel shell impaction with delayed presentation causing severe pain and hemorrhage and discuss the methodology employed for successful retrieval and management of such difficult shell ingestions.Figure: Impacted broken (umbo/dorsal) edge in crico-pharynx.Figure: Retrieved mussel shell with broken sharp (umbo/dorsal) edge and intact ventral beveled egde.Figure: Lacerations in the upper esophagus with bleeding.A 79 year old woman presented to ED with neck pain and spitting up blood after consumption of Italian seafood pasta 2 hours post consumption. She signed out against medical advice after initial ED presentation as she felt better and again presented to the ED 8 hours later with immense throat and neck pain and intermittent hematemesis. An urgent endoscopy revealed an impacted broken mussel shell in the upper esophagus with the broken beak/umbo/dorsal margin in the oropharyngeal sphincter (Image 1). This was grabbed with an alligator forceps and broken edge was snugged with the tip of scope to avoid lacerations and pushed down into the stomach. The shell was released in the fundus and subsequently grabbed with a Roth net. The broken sharp umbo/dorsal edge was snugged with the scope tip with ventrally beveled margins facing away to avoid trauma/laceration during withdrawal. The mesh of the net afforded some level of protection as well. Additionally, plenty of lubricant was applied on the scope externally and the scope was inserted all the way further down to pylorus to enable sufficient lubrication of esophagus prior to withdrawal of the Roth net with the broken shell. The shell was successfully withdrawn. Esophageal reintubation revealed lacerations akin to Mallory-Weiss tear in the upper esophagus (Image 3). This is a unique case presenting with hematemesis after consumption of Italian seafood pasta. Sea shell impaction should be suspected in such cases and our technique of grabbing the broken sharp (dorsal/umbo) edge and moving it down to stomach and providing enough esophageal lubrication and withdrawing in a Roth net, with the beveled ventral shell edge (Image 2) facing away from the scope, ensured a safe procedural outcome.