To the Editor: Symptoms after esophageal foreign body impaction vary from dysphagia to retrosternal discomfort. We describe an unusual, hitherto unreported presentation of an esophageal impaction. A 25-yr-old man was scheduled for urgent esophagoscopy after esophageal impaction from a meat bolus. Complaints included dysphagia, odynophagia, vomiting, and a foreign body sensation along with retrosternal discomfort 2 days after ingestion of meat. The discomfort in the retrosternal region was dull and aching in nature, nonradiating, increased on swallowing, had not increased in severity since its onset, and was not associated with any palpitations, syncope, breathlessness, or dysphoria. The findings from physical examination and laboratory investigations were unremarkable except for partial collapse of the left lung, along with evidence of pulmonary tuberculosis on the chest radiograph. A 12-lead electrocardiogram (ECG) showed evidence of myocardial infarction in the lateral wall (ST elevation in lead I/aVL with reciprocal changes in inferior leads), T-wave inversion in leads V1–V4, and a recent onset 2:1 atrioventricular (AV) block (Fig. 1). The acquired nature of the AV block and its recent onset were obvious from its presence in precordial leads and concomitant absence in limb leads. Because the limb leads are recorded first during a 12-lead ECG, followed by the precordial leads, this ECG captured the very moment of the onset of AV block (Fig. 1). Considering the possibility of the meat bolus leading to cardiac compression and thus inducing ECG changes, an urgent computed tomography scan was advised. Simultaneously, troponin levels were measured. The computed tomography scan showed the meat bolus to be impacted intraluminally at the midesophageal level (T5-7), with a maximum transverse diameter of 1.9 cm, and was compressing the left atrium and AV sulcus posteriorly (Fig. 2). Meanwhile, the troponin concentration was normal (0.05 μg/L). Esophagoscopy was conducted uneventfully under general anesthesia, with resolution of all ECG changes in the immediate postoperative period. Normal cardiac troponin levels and resolution of ECG changes after removal of the meat bolus suggested mass effect on the heart by the meat bolus as the likely etiology of the cardiac alterations.Figure 1.: Perioperative 12-lead electrocardiogram showing ST elevation in lead I/aVL with reciprocal changes in inferior leads, T-wave inversion in leads V1–V4, 2:1 atrioventricular block in precordial leads, and right axis deviation.Figure 2.: Computed tomography scan showing left atrial and atrioventricular sulcus compression.Previous reports of reversible ECG changes resembling those of myocardial ischemia or infarction from cardiac compression by extracardiac causes include a gastric tube located retrosternally after esophageal reconstruction, causing marked reversible ST-T changes due to cardiac compression.1–4 An anterior mediastinal tumor has also been reported to cause reversible ST-T changes, which disappeared after tumor removal.5 In a slight variation of these case reports, the cardiac compression in our patient was caused by a pressure effect from the posterior rather than the anterior mediastinum. A previous case report of left atrial and ventricular compression from the posterior mediastinum followed pyloroplasty, wherein a dilated stomach conduit resulted in sensation of chest compression along with ST elevation in leads II, III, and avF.6 The symptoms and ST changes subsided after nasogastric suction and decrease in stomach conduit size. This case suggests that a large esophageal foreign body may alter the ECG simulating myocardial ischemia or infarction, whereas in reality reflecting a mass effect on the cardiac chambers. Asha Tyagi, MD, DNB, MNAMS Nitin Behl, DA Debyani Dey, MD Shuchi Bhatt, MD Ashok K. Sethi, DA, MD UCMS and GTB Hospital Delhi, India [email protected]
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Open Access
Oct 1, 2011
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