Esophageal perforation caused by impacted hot potato successfully managed nonoperatively: A rare case report from Ethiopia and literature review

Abstract

Esophageal perforation represents a rare but life-threatening emergency that demands prompt diagnosis and multidisciplinary management to reduce associated morbidity and mortality. Although any esophageal segment may be affected, the thoracic esophagus is most frequently involved, with perforations typically resulting from iatrogenic causes, trauma, or spontaneous rupture. Food bolus-induced perforations are exceptionally uncommon, with perforation by impacted hot potato being extraordinarily rare—only 1 prior case has been reported in medical literature. Computed tomography (CT) plays an indispensable diagnostic role, with characteristic findings including focal esophageal wall discontinuity, extraluminal mediastinal gas, and adjacent fat stranding. We describe a 16-year-old male prisoner who presented with chest pain and dysphagia 48 hours after inadvertently swallowing a hot potato; CT confirmed thoracic esophageal perforation secondary to the impacted bolus. The patient was managed nonoperatively with excellent clinical outcome. To our knowledge, this represents only the second reported case of esophageal perforation caused by an impacted hot potato.

Introduction

Esophageal perforation, though rare, constitutes a serious life-threatening emergency requiring immediate diagnosis and coordinated multidisciplinary care to mitigate its significant morbidity and mortality. While perforation may occur in any esophageal segment, the thoracic esophagus represents the most frequently affected site [1,2]. Etiologies include iatrogenic causes (particularly endoscopic procedures, which account for the majority of cases), traumatic injury, and spontaneous rupture.

Of particular interest, food bolus-induced perforations remain exceptionally uncommon, with perforation secondary to impacted hot potato representing an extraordinary rarity - only 1 such case has been documented in medical literature.

Imaging serves as the cornerstone of both diagnosis and management strategy formulation. While chest radiography typically serves as the initial imaging modality, its findings often prove nonspecific. In contrast, chest CT emerges as the diagnostic modality of choice, reliably demonstrating characteristic features including focal esophageal wall discontinuity, wall thickening, periesophageal fluid collections, and pneumomediastinum [3].

We present the case of a 16-year-old male prisoner who developed chest pain and dysphagia 48 hours following hot potato ingestion, subsequently diagnosed with thoracic esophageal perforation through definitive CT findings. The patient achieved favorable outcomes through nonoperative management. To our knowledge, this represents only the second reported instance of esophageal perforation caused by impacted hot potato, with the single previous case involving a freshly microwaved potato.

Case report

A 16-year-old male prisoner presented to our emergency department with a 48-hour history of retrosternal chest pain and progressive dysphagia following accidental ingestion of a freshly cooked hot potato. The patient reported immediate onset of pain upon swallowing, with worsening dysphagia developing over the subsequent 24 hours. His medical history was unremarkable, with no prior surgical interventions.

On initial assessment, the patient was hemodynamically stable with normal vital signs: temperature 36.8°C, pulse rate 68 beats/min, blood pressure 116/78 mmHg, and oxygen saturation 94% on room air. Physical examination demonstrated normal cardiopulmonary findings, including equal bilateral air entry without adventitious breath sounds, absence of subcutaneous emphysema, and normal heart sounds. Abdominal examination was unremarkable.

Laboratory investigations revealed no abnormalities: leukocyte count 7.8 × 10³ cells/mm³ (reference range 4-10), normal serum electrolytes, and unremarkable hepatic and renal function panels. Initial chest radiography showed no evidence of pneumomediastinum or pleural effusion.

Given the high clinical suspicion for esophageal perforation and unavailability of urgent endoscopy, a contrast-enhanced thoracic CT was performed. The study demonstrated several key findings: First, an oval-shaped nonenhancing intraluminal mass at the mid-thoracic esophagus with proximal dilatation. Second, a focal full-thickness defect in the posterior esophageal wall at the level of the T5 vertebral body. Third, adjacent esophageal wall thickening with enhancement and surrounding fat stranding. Fourth, extraluminal air within the mediastinum without associated fluid collections (Figs. 1A–D). These findings confirmed the diagnosis of thoracic esophageal perforation secondary to impacted hot potato.

Fig. 1.

Axial (A) and sagittal (B) post contrast chest CT scans show mid esophageal region intraluminal foreign body measuring about 3 × 3.8 cm with dilatation of the esophageal lumen and full thickness posterior esophageal wall defect (Red and black arrows). Axial (C) and coronal (D) lung window showing pneumomediastinum.

The multidisciplinary team, including general surgery and gastroenterology, recommended nonoperative management based on the following factors: the patient's hemodynamic stability, contained nature of the perforation, absence of systemic sepsis, and favorable Pittsburgh Severity Score. Medical therapy included intravenous ceftriaxone (2 g daily) and metronidazole (500 mg every 8 hours). Endoscopic intervention was deferred due to the 48-hour delay in presentation and resolution of acute thermal injury.

The patient demonstrated rapid clinical improvement, with resolution of dysphagia and chest pain within 48 hours of admission. After close monitoring for 72 hours, he was discharged in stable condition with outpatient follow-up. Subsequent clinic visits confirmed maintained recovery without complications.

Discussion

Esophageal perforation constitutes a surgical emergency with mortality rates of 10-25%, where timely diagnosis and management significantly impact outcomes. The thoracic esophagus is particularly vulnerable, representing 54% of cases in contemporary series, with iatrogenic injury during endoscopic procedures accounting for the majority (59%) [1,2]. While traumatic and spontaneous (Boerhaave syndrome) etiologies are well-documented, foreign body-induced perforations remain uncommon, typically involving sharp objects like fish bones or caustic items such as button batteries [[4], [5], [6], [7], [8], [9]]. Our case presents an exceptionally rare mechanism: thermal-mechanical injury from an impacted hot potato, with only 1 analogous case previously reported [10].

The pathophysiology of potato-induced perforation involves unique material properties. Cooked potatoes retain heat exceptionally well due to their high water content (specific heat capacity 4.2 J/g°C) and low surface area-to-volume ratio. This creates prolonged tissue contact with temperatures exceeding 60°C - sufficient to cause full-thickness necrosis within minutes, as evidenced by our patient's transmural defect at T5. This contrasts sharply with typical food bolus injuries, which usually cause pressure necrosis over hours to days.

Diagnostically, CT has supplanted fluoroscopy as the gold standard, demonstrating 92%-98% sensitivity for perforation through 3 hallmark findings: direct wall discontinuity (seen in our case), periesophageal air, and fat stranding [3]. The absence of radiographic findings in our patient despite significant injury underscores CT's indispensable role. These imaging characteristics, combined with clinical stability (Pittsburgh Severity Score = 2), supported our decision for nonoperative management - an approach successful in 78% of contained perforations [11]. These imaging characteristics, combined with clinical stability (Pittsburgh Severity Score = 2), supported our decision for nonoperative management - an approach successful in 78% of contained perforations [11]. This case highlights 2 critical insights: first, radiologists should consider thermal injury when interpreting perforations caused by heat-retentive foods like potatoes, which may mimic mechanical trauma; second, CT findings can reliably guide conservative management in stable patients with contained leaks and absent sepsis.

Conclusion

Esophageal perforation caused by impacted hot potato represents an exceptionally rare clinical entity, with only 2 documented cases worldwide including ours. Patients may present with variable clinical severity depending on the degree of mediastinal contamination, ranging from stable conditions to life-threatening mediastinitis or sepsis. CT scan serves as the cornerstone for both definitive diagnosis and therapeutic planning, accurately delineating the extent of esophageal injury and associated complications. Nonoperative management demonstrates excellent outcomes in hemodynamically stable patients with contained leaks, as evidenced by our case. Given the global ubiquity of potato consumption, clinicians should consider this unusual etiology when evaluating patients with acute chest discomfort and dysphagia following hot potato ingestion, particularly given the delayed presentation often seen with thermal injuries.

Patient consent

Informed consent was obtained from the patient to publish this case report. Personal identifiers are not used in this paper.