Foreign body esophagus: Six years of silence

Abstract

Foreign body esophagus remains one of the common medical emergencies which may lead to significant morbidity and mortality. Sharp objects, batteries, and elderly with foreign body esophagus should be treated with emergent removal owing to the complications that might ensue. Endoscopic removal is the preferred choice of treatment but for large foreign body, sharp foreign body, and so on, rigid esophagoscopic removal might be more preferable. Foreign body esophagus though an obvious situation might at times be missed. It is important to make an early definitive diagnosis. We report a unique case of missed foreign body (denture) esophagus despite the obvious signs and symptoms. Definitive diagnosis was made only after 6 years due to the lack of definitive diagnostic procedures and expertise. The foreign body was impacted in the mucosal wall of the esophagus requiring Gastric resection and anastomosis (with McKeown procedure). With this we have tried to highlight the pitfalls in the diagnosis and management of foreign body esophagus. We report a case of a 55-year-old female who presented to the Emergency Room with history of progressive dysphagia and odynophagia for 6 years which was aggravated for the past 6 months. A radiological diagnosis was made. It was followed by a failed attempt of endoscopic removal which warranted the surgical removal of the foreign body.

Introduction

Foreign body (FB) esophagus remains one of the common medical emergencies which may lead to significant morbidity and mortality.¹ It is common among pediatric age group, elderly, prisoners, and patients with psychiatric illness and mental retardation. Most of the cases of FB esophagus would pass spontaneously but those that require intervention should however, be treated as soon as possible. Sharp objects, batteries, and elderly with FB esophagus should be treated with emergent removal owing to the complications that might ensue. Endoscopic removal is the preferred choice of treatment but for large FB, sharp FB, and so on, rigid esophagoscopic removal might be more preferable.² Plain radiographs are the first line of investigation and diagnostic in most of the cases. However, other modalities of diagnosis like upper gastrointestinal (GI) endoscopy and computed tomography (CT) scan chest and abdomen are required in cases where plain radiographs fail to make a definitive diagnosis. Very few cases of surgical intervention have been reported. Surgical approach usually is considered in cases where endoscopic removal fails.³ Similar was the case in our patient. It took 6 years for the patient to get the proper diagnosis and surgical management done. Most important of all, she adds up to those very few percentage of people (<1%) that undergo surgical intervention.

Case report

A 55-year-old female presented to the Emergency Room (ER) with progressive dysphagia for 6 years. It was getting worse for the past 6 months. She also gave a history of accidental swallowing of denture 6 years back. With the complaints of progressive dysphagia, she had been visiting the primary health care hospitals on a regular basis. According to the patient, she had undergone X-ray neck multiple times but none reaching to a definitive diagnosis. Every time she was prescribed some pain medications and antacids. Her condition was degrading so much so that in the past couple of months before the definitive diagnosis, she was only able to take semisolid diet. Thus, they finally visited a higher center in a nearby city where a definitive diagnosis of FB esophagus was made via an upper GI endoscopy. She was then referred to tertiary care center for further management. When she visited our hospital, she looked pale and cachexic but didn’t complain of odynophagia, fever, or shortness of breath. Her vital signs were within normal range. Repeat X-ray soft tissue neck and chest was clear. Contrast enhanced scan of neck and chest was done which revealed irregular hyperdense structure with irregular linear projections lodged at the level of lower esophagus (Figure 1). Hence a FB (denture) esophagus was confirmed. Endoscopic removal was not successful. Discussion was done with Cardiothoracic and Vascular Surgery team and the final decision of surgical intervention was made. Ultimately, the patient underwent Gastric resection with resection anastomosis (McKeown procedure). Intraoperatively, a denture measuring around 10 cm × 5 cm was identified. It was embedded in the esophageal mucosa few centimeters above the Gastroesophageal junction (Figure 2). Post removal FB is shown in Figure 3. Feeding jejunostomy was placed. Postoperative period was uneventful. The patient was kept under IV antibiotics for 10 days and discharged. The feeding jejunostomy was removed after 6 weeks with no further complications.

Figure 1.

CT neck and chest showing hyperdense shadow impacted in the lower esophagus.

Figure 2.

Intraoperative removal of foreign body (denture) esophagus.

Figure 3.

Foreign body esophagus (denture) post removal.

Discussion

With an annual incidence of 11 per 100,000 persons in the United States, FB still accounts for one of the common medical emergencies. It is more common among children and elderly followed by people with mental or neurological disorders. Studies have shown that food bolus, bones pieces, and dentures (4%–18%) were found more common in elderly and coins and toys more in children.² The cause of FB impaction in adult population has been found to be luminal narrowing of esophagus by webs, rings, strictures, tumors, achalasia, and esophagitis. In children, immature oropharyngeal coordination has been suggested.⁴

In elderly people, removal of impacted dental prosthesis can be a challenging problem. Delay in diagnosis and removal can lead to significant morbidity and mortality. The metal clasps or retaining wires in the dentures predispose them to impaction when ingested.⁵ Sharp foreign bodies when ingested may cause mucosal edema leading to airway compression, mucosal ulceration, inflammation, abscess, mediastinitis, empyema, perforation, FB migration into adjacent structures, fistula, and so on.²

Plain radiographs are diagnostic in most of the cases; however, in cases where plain radiographs are not sufficient, upper GI endoscopy and CT scan can add some value like in our case.⁶

Although majority of the foreign bodies are found to pass spontaneously without need of any intervention, every case should be treated as a medical emergency owing to the number of complications. Thus, the mainstay of management is early diagnosis and removal of the FB. Prior to 1947, rigid esophagoscope was the one routinely used. In 1966, removal of FB by Foleys catheter was reported by Richardson. Flexible esophagscopy became famous by 1970s and 1980s.⁷ Very few cases of surgical intervention have been reported. Surgical approach usually is considered in cases where endoscopic removal fails with few deciding factors like age > 70 years, foreign bodies in upper esophagus, maximal diameter of FB > 30 mm, and the time of presentation > 2 days.^3,8 In our case, thoracotomy and anastomosis surgery with gastric resection was performed due to failure of flexible endoscopy. Intraoperatively, a denture measuring 10 cm × 5 cm was removed from lower esophagus (Figure 3). However, there were no postoperative complications. Feeding jejunostomy was placed in situ which was removed 6 weeks later.

Conclusion

FB esophagus is a common condition. It is more commonly seen in elderly and pediatric age group. No active intervention is required in majority of the cases. However, in certain percentage, surgical removal is required. Complications are rare but possible like in our case where the FB if goes unnoticed can migrate out of the lumen causing complications. So a proper diagnosis and early intervention must be done.