S2764 A Novel Cause of Odynophagia From Unintentional Foreign Body Introduction During EGD With Dilation

Abstract

INTRODUCTION: Esophageal dilation is a valuable treatment option for multiple symptoms including dysphagia. Like all procedures, dilation carries its own unique risks including iatrogenic injury. We present a patient who underwent dilation and suffered a medical error when a sterilization indicator strip was inadvertently placed and left in her esophagus. CASE DESCRIPTION/METHODS: An 88-year-old female presented to a referring hospital with suspected food bolus impaction. The week prior, she had undergone an esophageal dilation for solid food dysphagia. The day after the procedure, she developed intermittent, spasm-like substernal chest pain. Her symptoms worsened to include dysphagia, hematemesis, regurgitation, and inability to tolerate her saliva which prompted her to return to the hospital. On arrival, her vitals, labs, EKG, and CXR were within normal limits and without acute findings. A CT scan of the chest demonstrated a dilated esophagus with intraluminal contents at the upper thoracic inlet. Upon transfer to our facility, GI recommended a trail of glucagon. She continued to have symptoms, which prompted an evaluation with EGD. This revealed a stiff, plastic-like foreign body in the upper esophagus. The distal edge was embedded within the esophageal mucosa causing ulceration and raising concern for impending perforation (Figure 1). Attempts were made to remove the object using a raptor grasper. Eventually, the object was removed with a jumbo oval snare. There were no deep mucosal tears or active bleeding noted after removal (Figure 2). The object was identified as a sterilization indicator strip which was almost certainly introduced at her dilation the week prior (Figure 3). An esophagram revealed moderate esophageal dysmotility without stricture, mass, or evidence of contrast extravasation. She was ultimately discharged home on a PPI with outpatient GI follow-up. DISCUSSION: In the patient presented, we do not know the type of dilator used or if any complications were encountered during dilation. We suspect the indicator strip was introduced either through a pre-dilation EGD or stuck to the dilator itself. Indicator strips can take a concave shape which allows them to adhere to round equipment reprocessed for GI procedures. Given the reduced lighting during these procedures, careful inspection of equipment is necessary to avoid missing these objects. Perhaps by standardizing a post-dilation EGD to evaluate for complications, this could have been addressed sooner.Figure 1.: Foreign Body Located in the Proximal Esophagus.Figure 2.: Esophagus following Foreign Body Removal.Figure 3.: Foreign Body after Removal from the Esophagus.