Unusual Esophageal Foreign Body

Abstract

Question: A 38-year-old man presented with complaints of mild dysphagia after the ingestion of a dinner fork about 1.5 hours ago, while attempting to induce vomiting. Physical examination was unremarkable, with no hypersialosis or subcutaneous emphysema. Blood sample analysis was normal. A plain chest radiograph revealed a radiopaque fork in the esophagus without evidence of pneumomediastinum (Figure A, B). Because the patient arrived during the night and was asymptomatic, the attempt to extract the foreign body endoscopically was organized on the following morning to so that a digestive surgeon could see the patient if perforation occurred during removal. The examination was performed under general anesthesia with endotracheal intubation. What is your diagnosis? Look on page 604 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. At the time of the upper gastrointestinal endoscopy, the fork had migrated to the stomach without injury to the upper gastrointestinal tract (Figure C). It was successfully removed, the end of the tines ahead, and gripped by a rat tooth grasping forceps, using a protector hood to avoid perforating the esophagus (Figure D). When the fork reached the upper esophageal sphincter, the neck was flexed in hyperextension to align the axis of the esophagus and the pharynx to allow the manual removal of the fork with the help of a Magill forceps. We describe a case of fork ingestion in the esophagus as part of a rare eating disorder consisting in self-induced vomiting. Cases of fork ingestion in the esophagus are rarely described in the medical literature. Ingestion of a fork is described in 2 circumstances: self-induced vomiting (an eating disorder) and attempts to stop a chronic hiccup. Because long objects are unlikely to pass through the stomach, endoscopic removal is compulsory and requires a skilled endoscopist as well as accessories, because the removal of sharp and pointed objects have a higher risk of perforation. Different techniques have been described to remove forks from the upper gastrointestinal tract1Birk M. Bauerfeind P. Deprez P. et al.Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.Endoscopy. 2016; 48: 489-496Crossref PubMed Scopus (276) Google Scholar: strong-toothed graspers with the help of a protector hood, double wire-loop snare technique, or surgically gastrotomy. The main principles of endoscopic removal are to orient the long axis of the object in the line of removal and to present the blunt end as the leading end. Devices developed to protect the gastrointestinal tract during the removal of any sharp object include soft latex protector hoods and overtubes. However, the pointed ends of a metallic fork could perforate the soft latex of a protector hood and injure the esophagus.2Bertoni G. Sassatelli R. Conigliaro R. et al.A simple latex protector hood for safe endoscopic removal of sharp pointed gastroesophageal foreign bodies.Surg Endosc. 1992; 6: 255-258Crossref PubMed Scopus (22) Google Scholar In our patient, a systematic gastrograffin study and computed tomography scan confirmed the absence of iatrogenic perforation and the patient was discharged from hospital with advice to seek for psychiatric follow-up. We thank Yves Horsmans (Department of Gastroenterology, Cliniques universitaires Saint-Luc, UCL, Brussels, Belgium) for critically reading the manuscript.