Abstract
Case
We investigated the usefulness of multidetector computed tomography during examination in the emergency department to detect the location of press‐through packages that had been inadvertently swallowed. In three patients, four press‐through packages were detected on multi‐planar reconstruction of multidetector computed tomography images, with three lodged in the esophagus and one in the stomach.
Outcome
The multidetector computed tomography detection rate of press‐through packages was 100% in patients who realized they had swallowed the packages by mistake. After diagnosis, press‐through packages in the esophagus were immediately removed endoscopically.
Conclusion
There are few reports on the usefulness of multi‐planar reconstruction images by multidetector computed tomography during examinations in the emergency department for the diagnosis of foreign bodies in patients who have mistakenly swallowed press‐through packages. Detecting the location of the packages provided useful information regarding the strategy for their removal. Therefore, proactive multidetector computed tomography use in the emergency department could be beneficial for patients who have inadvertently swallowed press‐through packages.
Keywords: Drug packaging, emergency service, foreign bodies, multidetector computed tomography
Introduction
Early and accurate diagnosis and treatment of foreign body ingestion are important to avoid complications. For patients presenting with mistakenly swallowed press‐through packages (PTPs), detection is difficult because of their radiolucency. However, there are increasing reports that the location of a PTP can be detected by multidetector computed tomography (MDCT).1, 2, 3, 4, 5, 6, 7, 8 We present three such cases, together with a review of published work, to emphasize the importance of early diagnosis. In these three cases, PTPs were discovered in the esophagus or stomach by MDCT during examination in the emergency department (ED).
Methods
This case report aimed to investigate the usefulness of MDCT examination to detect the location of PTPs in patients who realized that they had accidentally swallowed one or more tablets or capsules still in their PTPs. We used a 4‐row MDCT (Toshiba Aquilion 4‐Slice CT; Toshiba, Tokyo, Japan) to locate the PTPs.
There were three such cases in our ED from April 2010 through November 2012, in which all the patients realized that they had swallowed a PTP by mistake. We used the MDCT examination to determine the locations of PTPs in their upper digestive tract because the PTPs would not be discernible on radiographs. We subsequently developed a plan of treatment for each patient according to the results of their MDCT examinations.
Case 1
A 76‐year‐old woman presented to our ED with the complaint of discomfort in her neck. The patient realized that she had inadvertently swallowed a ubidecarenone tablet still in the PTP. We could not locate the PTP by plain chest radiography or by two soft‐tissue views of her neck (Fig. 1A–C). Consequently, we carried out an MDCT, which revealed that the PTP was lodged in her thoracic esophagus (Fig. 1D,E). During emergency upper gastrointestinal (UGI) endoscopy, the PTP was confirmed to be stuck in her esophagus just above the esophagogastric junction. We removed the PTP with forceps, through a plastic cover attached to the endoscope, without any complications (Fig. 1F–H). She was discharged from the hospital a few hours later.
Figure 1.
Chest radiograph and multidetector computed tomography images of a 76‐year‐old woman who inadvertently swallowed a ubidecarenone tablet still in its press‐through package. A–C, Chest radiograph and soft views of the neck did not detect any foreign bodies. D, E, Multidetector computed tomography shows a foreign body in the thoracic esophagus (mediastinal‐window and lung‐window views, respectively). F–H, The press‐through package that had been lodged immediately above the esophagogastric junction was removed without any complications using forceps through a plastic cap attached to the endoscope.
Case 2
A 40‐year‐old man presenting to our ED was asymptomatic but was worried that, after drinking 2 h earlier, he might have inadvertently swallowed a mecobalamin tablet still in the PTP. Plain neck, chest, and abdominal radiographs revealed no PTP. Therefore, we carried out an MDCT and detected a high‐density object mixed with his stomach contents, which we suspected to be the ingested PTP (Fig. 2). Due to the presence of partially digested food in the stomach, we agreed to postpone the procedure after discussing the risks with him. An outpatient UGI endoscopy was carried out 12 h later. Although it revealed no injuries to the stomach lining, the PTP was not evident. We explained the need for further observation and careful follow‐up at the outpatient clinic. Two days later, the patient confirmed that the PTP had passed naturally without any further problems.
Figure 2.
A–C. Plain chest, abdominal, and neck radiographs failed to detect a press‐through package (PTP) inadvertently swallowed by a 40‐year‐old man. The same type of PTP was placed beside the patient's neck, demarked by the white circle, but it did not appear in the radiograph. D, E. Multidetector computed tomography revealed a high‐density object, which was strongly suspected of being a PTP, in the stomach in the digested food (mediastinal‐window and lung‐window views, respectively).
Case 3
An 83‐year‐old woman presented with the complaint of a sore throat and retrosternal pain after mistakenly ingesting two different PTPs, a pyridoxal phosphate hydrate and a teprenone approximately 2 h earlier. She was transferred to our ED from her local dentist. We determined the location of the two PTPs, just as the patient had told us, in the middle esophagus using reconstructed chest MDCT images (Fig. 3A–E). The MDCT revealed no emphysema or perforations of the esophagus. Using the methods described in Case 1, we carried out an emergency UGI endoscopy to remove both PTPs (Fig. 3F–I) as carefully and safely as possible. Again, as in Case 1, there were no complications, so the patient was not admitted. Identifying the locations of the PTPs was helpful when determining the optimal strategy for their removal.
Figure 3.
Multidetector computed tomography revealed a press‐through package (PTP) in the esophagus of an 83‐year‐old woman who mistakenly ingested two different PTPs: pyridoxal phosphate hydrate, shown in axial (A), coronal (B), and sagittal (C) views; and teprenone, shown in axial (D) and sagittal (E) views. F, H, Endoscopic views of the pyridoxal phosphate hydrate and teprenone PTPs, respectively. G, I, Pyridoxal phosphate hydrate and teprenone tablets, respectively, in PTPs.
Discussion
Inadvertent PTP ingestion is being diagnosed more frequently in cases of foreign bodies in the digestive tract.1, 2, 3, 4, 5, 6, 7, 8 Radiological tests play a very important role in revealing the location of PTPs that have been inadvertently swallowed. However, contrary to popular opinion, preoperative confirmation of PTPs in the UGI tract is difficult due to their radiolucency.5
Computed tomography may be helpful when plain radiographs are negative, because CT images are more sensitive due to their high spatial and density resolution. However, in patients with penetration or perforation caused by a PTP, Suzuki et al. reported a CT detection rate of only 19% (13/69).7 An increasing number of reports have shown that PTP locations were successfully detected by MDCT examinations. For example, Suwa et al. reported that, although conventional CT could not detect a PTP, they arrived at a definitive diagnosis with MDCT volume rendering (VR) images.8
Using volume rendering and multi‐planar reconstruction (MPR) of MDCT images, Takano et al. reported that PTPs were visible as high‐density oval‐shaped shadows, representing the tablet and air bubble in the plastic dome.2 Takada et al. mentioned the PTP appeared as a triple‐contrasted target lesion, consisting of high, low, and slightly lower densities; these corresponded to the tablet, air in the PTP dome, and surrounding water, respectively.1 In the present study, MDCT examinations detected all the PTPs containing drugs, in either the esophagus or stomach, as high‐density tablets or capsules and air, trapped within the packages.
In this study, we verified PTPs on MDCT by comparison with the same type of PTPs laid out on a flat surface (Fig. 4). We could clearly identify the aluminum sheets as high‐density linear shadows. Using MPR images, MDCT facilitated the diagnosis of one or more PTPs in the UGI tract of all three patients by detecting the tablet or capsule as a high‐density oval‐shaped shadow and/or air bubble in the plastic dome. Multidetector computed tomography can create images in any plane, and hence can detect a PTP in the patients' digestive tract in any plane. Therefore, PTPs were visible regardless of their location or aspect in the UGI tract.
Figure 4.
Press‐through packages in the upper gastrointestinal tracts of three patients were verified using multidetector computed tomography by comparing them with the same type of packages laid out on a flat surface A, Ubidecarenone. B, Mecobalamin. C, Pyridoxal phosphate hydrate. D, Teprenone.
According to the 2002 guidelines of the American Society for Gastrointestinal Endoscopy,9 persistent esophageal symptoms following suspected foreign body ingestion should be pursued with endoscopy, regardless of the radiographic evaluation. Removal of a PTP with UGI endoscopy should be attempted as soon as possible after swallowing to avoid future complications. Previously, most published reports concerned hospitalized patients who suffered from peritonitis due to intestinal or colonic perforation caused by one or more ingested PTPs.1, 2, 3, 4, 6, 7, 8 To our knowledge, only one report has evaluated the usefulness of MDCT in the ED for PTP detection in the UGI tract.5 No reports have mentioned the numbers of the MDCT detectors, except that by Takano et al. who used a 16‐row CT.2 For the three cases in our study, we used the four‐row MDCT with good results. Because of these outcomes, we believe the four‐row MDCT is adequate to detect PTPs in the upper GI tract.
In Cases 1 and 3, we decided that we should remove the PTPs after establishing the diagnosis with MDCT. In Case 3, two different PTPs, just as the patient had told us, were lodged in the patient's esophagus. We then proceeded to carry out emergency endoscopy to remove them as gently as possible. However, in Case 2, the PTP was in the stomach, mixed in with recently digested food. Considering the risks of removal, we opted to carry out an endoscopy 12 h later. However, we could not detect the PTP in his stomach. Therefore, we explained to the patient that the majority of ingested foreign objects are generally defecated without complications once they have passed into the lower digestive tract.10 The PTP was passed in this way, and the patient reported no further concerns.
Hou et al. emphasized that early CT examination should be considered in symptomatic patients to avoid any possible complications.3 In the present study, detecting the location and the number of PTPs was useful in treatment planning. Because the treatment would differ depending on the location of the PTP, MPR images obtained from MDCT can be invaluable in providing the PTP's precise location.
Conclusions
Although the present study was limited in that we only identified three cases, the MDCT detection rate of PTPs was 100% in patients who realized that they had inadvertently swallowed one or more PTPs. Together with the review of published reports, this may suggest that MPR images are useful for detecting mistakenly ingested PTPs. MDCT in the ED can accurately confirm the presence, location, and number of PTPs, while providing valuable information on the optimal treatment strategy. Emergency department physicians should use the MDCT proactively, being aware of its effectiveness for patients who have mistakenly swallowed one or more PTPs.
Conflict of Interest
None.
References
- 1. Takada M, Kashiwagi R, Sakane M, Tabata F, Kuroda Y. 3D‐CT diagnosis for ingested foreign bodies. Am. J. Emerg. Med. 2000; 18: 192–193. [DOI] [PubMed] [Google Scholar]
- 2. Takano A, Tsushima Y, Takahashi A et al Press through package (PTP) ingestion diagnosed by multi‐detector (MD) CT: a case report. Jpn. J. Clin. Radiol. 2005; 50: 1693–1696. (in Japanese.) [Google Scholar]
- 3. Hou SK, Chern CH, How CK, Wang LM, Huang CI, Lee CH. Press through package mis‐swallowing. Int. J. Clin. Pract. 2006; 60: 234–237. [DOI] [PubMed] [Google Scholar]
- 4. Bosmans JM, Spinhoven MJ, Deckers FP, Pouillon MM, Borre FJ, Parizel PM. Accidental ingestion of a press‐through package: An underestimated cause of serious iatrogenic disease in the elderly? J. Am. Geriatr. Soc. 2006; 54: 1467–1468. [DOI] [PubMed] [Google Scholar]
- 5. Sudo T, Sueyoshi S, Fujita H, Yamana H, Shirouzu K. Esophageal perforation caused by a press through pack. Dis. Esophagus 2003; 16: 169–172. [DOI] [PubMed] [Google Scholar]
- 6. Yamaguchi H, Yamashita H, Yamauchi H, Suzuki T, Ishimaru M, Nagawa H. Intestinal perforation caused by stagnated press‐though packages. Surgery 2005; 137: 661–662. [DOI] [PubMed] [Google Scholar]
- 7. Suzuki S, Kimura H, Kunisaki R. A case of ileal penetration with Crohn's disease due to a press through package diagnosed preoperatively. J. Jpn. Soc. Coloproctol. 2012; 65: 283–287. (in Japanese.) [Google Scholar]
- 8. Suwa H, Kobayashi H, Baba N. A case of preoperatively diagnosed penetrative peritonitis of the ileum using MDCT, caused by mis‐swallowing a PTP (press through package). J. Jpn. Surg. Assoc. 2007; 68: 486–490. (In Japanese.) [Google Scholar]
- 9. Eisen GM, Baron TH, Dominitz JA et al Guideline for the management of ingested foreign bodies. Gastrointest. Endosc. 2002; 55: 802–806. [DOI] [PubMed] [Google Scholar]
- 10. Read TE, Jacono F, Prakash C. Coloenteric fistula from chicken‐bone perforation of the sigmoid colon. Surgery 1999; 125: 354–356. [PubMed] [Google Scholar]