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Thread: A 21-Year-Old Man With an Interesting Radiologic Finding

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    Default A 21-Year-Old Man With an Interesting Radiologic Finding

    A 21-year-old white man presents to the emergency department with a 10-hour history of epigastric pain that is radiating to the chest. The pain is constant, localized, and sharp in nature. He was at a party the previous night and admits to drinking alcoholic beverages but denies any illicit drug use. There is no associated nausea, vomiting, or indigestion, and he denies ever having suffered from this pain in the past. The patient gives no history of shortness of breath, palpitations, or syncope. There is no history of trauma to the epigastrium, and the patient does not remember anything that may be causing his symptoms. His past medical history is significant for an appendectomy 9 years ago and surgery for a deviated nasal septum 11 months ago. He is not currently on any regular medication. There is no history of allergies. His family history is negative for any cardiac or abdominal pathology. He smokes approximately a pack of cigarettes a day and admits to binge-drinking alcohol at weekend parties.

    On examination, he appears to be alert, comfortable, and in no acute distress. He is well oriented to person, time, and place. His vital signs reveal a heart rate of 76 bpm, a respiratory rate of 18 breaths/min, and an O2 saturation of 97% on room air. His temperature is normal. His respiratory and cardiovascular examinations reveal no abnormal findings. The abdominal examination reveals no abnormal findings on inspection, except for a well-healed appendectomy scar; otherwise, the abdomen is scaphoid and without any discoloration, bruises, or visible abnormalities. Palpation reveals a slightly tender but otherwise soft epigastrium, with positive bowel sounds and no evidence of guarding or rebound tenderness. No masses or organomegaly are appreciated, and the abdomen is resonant to percussion, with the absence of a fluid wave or shifting dullness. The spleen and liver margins are normal and the kidneys are not palpable. Neurologic examination is grossly normal with equal power, tone, and bulk in both upper and lower extremities bilaterally, normal reflexes, and intact cranial nerves. His mental status exam is normal.

    Laboratory investigations reveal a hemoglobin count of 16.9 g/dL (169 g/L) and a white blood cell count of 7.8 103/L (7.8 109/L). Urea and electrolytes are within normal limits, and there is no derangement of liver function. Serum amylase is normal. A chest x-ray shows clear lung fields, a normal heart size, and no evidence of air under the diaphragm; however, the chest and abdominal x-rays do reveal a radio-opaque shadow in the central lower chest/epigastrium region. Electrocardiography shows a sinus rhythm with no evidence of ischemic changes. The patient is instructed to take nothing orally and is placed on intravenous fluids. His symptoms are persistent, and a repeat chest and abdominal x-ray at 12 hours post-admission shows that the previously seen shadow has not changed position. The decision to intervene endoscopically is made.



    What is the abnormality seen on the x-ray?

    Hint: Take a closer look at the chest and abdominal x-rays.


    External monitoring device
    Radiologic artifact
    Foreign-body ingestion
    An implanted medical device
    Correct Answer & Discussion

    In this case, the chest and upper abdominal x-rays revealed that the patient had ingested a foreign body, which appeared to be lodged at the gastroesophageal junction. There was no radiologic or clinical evidence of air in the mediastinum or under the diaphragm, which ruled out an upper gastrointestinal perforation. The patient admitted to uncapping the bottles of alcoholic beverages with his teeth. He had accidently swallowed one such metallic bottle cap that, having impacted at the gastroesophageal junction, was responsible for his symptoms. The patient's own inebriation probably caused him to swallow the foreign body and was also the reason why he could not remember swallowing it. The patient denied any recent problems with swallowing solids or liquids, but he had not tried ingesting any solid food since the occurrence of the incident. A common symptom of total luminal obstruction is the inability to swallow one's own secretions. This was not the case here, and presumably some fluids were able to bypass the obstruction.

    Gastrointestinal foreign objects are either ingested (intentionally or accidently) or inserted rectally. They are encountered in all age groups but are more commonly seen in children between 6 months and 6 years of age.[1] In adults, they are found more frequently in those with psychiatric or behavioral problems, and, as in this case, in cases of alcohol intoxication.[1] Foreign-body ingestion may also occur accidently in patients who have dental prostheses. In the United States, approximately 1,500-1,600 deaths occur annually due to foreign-body ingestion or insertion.[2] A wide variety of foreign objects may be found in the gastrointestinal tract; a review of foreign bodies found in the gastrointestinal tract of patients who presented to the emergency department in London showed that the most common objects were coins (18.4%), aerosol caps (rectally; 10.5%), metal blades (10.5%), and AA batteries (7.9%).[2] Disc batteries are especially dangerous if ingested because they can cause caustic injury and quickly result in tissue necrosis and esophageal perforation. Intentional gastrointestinal foreign-body ingestion and insertion are more common than accidental occurrence in the adult population.

    The diagnosis is usually made on the basis of the patient history and appropriate imaging; however, making the diagnosis can be difficult because the majority of patients who ingest foreign objects are either children or those in whom a proper history-taking would prove challenging (such as psychiatric patients or intoxicated patients). These patients may only present after the onset of symptoms such as choking, pain, refusal to eat, vomiting, wheezing, or respiratory distress.[1] Examination may reveal swelling, erythema, tenderness, or crepitus in the neck; additionally, the abdomen may also show signs of obstruction or peritonitis secondary to perforation.[1] A study from 2006 showed that a majority (39.5%) of patients presented with no clinical signs or symptoms, and only 10.5% presented with abdominal pain.[2] Radiologic investigations are used to localize the object. X-rays can identify most foreign objects and free air in the mediastinum or peritoneum. In the previously mentioned study, 87% of foreign objects were identified on plain x-ray.[2] A lateral x-ray may help identify multiple foreign bodies, such as coins, or it may help differentiate a coin from a disc battery.[1,3] Serial x-rays over a period of time may show the progress of the foreign body through the gastrointestinal tract if the object is small, has no sharp edges, and the patient is stable. Some objects, such as fish bone, plastic, or glass, are more difficult to see on x-rays.[1] A computed tomography scan or contrast study may help locate more difficult objects.[1]

    The risks of a foreign body in the alimentary canal are impaction, perforation, obstruction, erosion, and fistulation anywhere along the gastrointestinal tract. Rounded and/or smooth objects, such as coins, pass more easily than sharp objects.[3] Anatomically, the esophagus is one of the narrowest sections of the gastrointestinal tract,[3] which makes it a common site of foreign-object impaction. Other common sites include the pyloric channel and ileocecal valve. The esophagus is about 7.9-9.4 in (20-24 cm) long, starting 5.5-6.3 in (14-16 cm) distal to the incisor teeth[4] at the upper esophageal sphincter. This is the narrowest part of gastrointestinal tract. It is formed by the cricopharyngeal fibers of the constrictor muscles of the pharynx.[4] Distally, the esophagus also narrows at sites where it is indented by the aorta, the left main bronchus, and the heart [4]; these are also sites for potential foreign-body impaction. The most common site of foreign-body impaction is at the level of the thoracic inlet,[1] followed by the gastroesophageal junction.[3] Once an object passes through the esophagus into the stomach, the risk of it lodging somewhere along the rest of the alimentary canal is relatively small, even for sharp objects.[1,3] Sharp objects that have passed into the stomach, however, still pose a 35% risk for complication, and most authorities recommend that removal be attempted.[7] A Chinese study showed that 84.5% of 439 patients with foreign-body ingestion had the object lodged in the esophagus, with the majority in the upper esophagus.[5]

    Management of patients with ingested foreign bodies depends on the age and clinical condition of the patient as well as the size, shape, and nature of the object (eg, sharp, corrosive, or poisonous)[1] and the site at which the foreign body is lodged. Foreign objects should not remain in the esophagus for more than 24 hours from the time of presentation to the emergency department.[1] It is usually recommended that endoscopy be performed within that timeframe. The majority of foreign bodies pass through the gastrointestinal tract without requiring intervention, whereas 10%-20% of foreign bodies require nonoperative intervention and less than 1% require surgery (eg, laparotomy).[5] Upper gastrointestinal endoscopy can be used to remove the foreign body. Initial attempts to dislodge a food bolus are usually made with ingestion of a carbonated beverage or via intravenous glucagon; however, this is not done with foreign-body ingestions. Ingested foreign body is the second most common indication for emergency endoscopy (gastrointestinal bleeding is the first).[5] During endoscopy, forceps are more successful in removing sharp objects, while the basket is more successful in removing blunt objects, such as coins or a food bolus.[5] An overtube or protector hood should be used to avoid puncture of the esophagus and/or aspiration on withdrawal. Failure of endoscopic removal usually means that the foreign body in question is a bone, with 76.5% of cases being fish bone,[5] usually in the upper esophagus.[5] It is important to keep in mind the potential for luminal abnormalities that result in obstruction. An esophageal stricture, achalasia, esophageal diverticula, and eosinophilic esophagitis are common pathologies that are found at follow-up endoscopy.

    An American study concluded that adopting a conservative approach in the asymptomatic patient allowed spontaneous passage of nearly all swallowed foreign objects.[6] This study did not include corrosive objects or those stuck in the esophagus. Narcotic packets concealed internally for drug trafficking should be allowed to progress through the gastrointestinal tract naturally.[1] If removal becomes a necessity because of obstruction or rupture of the packet contents, endoscopic removal should not be attempted because of the risk for iatrogenic rupture and leakage of the drug packets, leaving surgical intervention as the only choice.[1]

    Summary
    To summarize, any esophageal foreign-body obstruction should be treated endoscopically within 24 hours. Disk batteries pose the highest risk for caustic injury and perforation. Luminal abnormalities must be excluded at the site of obstruction, usually through follow-up endoscopy. There is more variation in practice with respect to the management of a foreign body that has reached the stomach. Some centers will take a liberal wait-and-watch approach for passage of even large (0.8-2 in [2-5 cm] oval or 2.4-3.9 in [6-10 cm] long) and sharp objects. Most endoscopists, however, will attempt removal of foreign-body obstructions larger than 0.8 in (2 cm) in circular diameter and/or more than 2.4 in (6 cm) long, as these are deemed unlikely to pass the pyloric channel and duodenal sweep, respectively. Sharp objects that remain in the stomach still carry a small but significant risk for complication if left untreated, and regulatory bodies generally recommend that they be removed endoscopically if possible.[8]
    Case Resolution
    The patient in this case was observed for 12 hours. His symptoms did not resolve and he continued to have epigastric and chest pain. Repeat x-rays of the chest and abdomen revealed that the foreign body had not moved from the gastroesophageal junction. An emergency esophagogastroduodenoscopy was performed to retrieve the bottle cap within 24 hours of the patient presenting to the ED. The metallic bottle cap was visualized at the gastroesophageal junction, and it was pushed down into the gastric cardia before retrieval. There was no other endoscopic abnormality of the upper gastrointestinal tract apart from associated gastritis. Initial attempts at retrieval of the bottle cap with the large biopsy forceps failed because the cap dropped back into the stomach upon reaching into the gastroesophageal junction. It was successfully removed with a basket net. The patient was later discharged from the hospital and warned about the dangers of uncapping bottles with his teeth.




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    Lightbulb Self-Assessment

    A concerned mother comes to the emergency department with her tearful 1-year-old child, who she believes swallowed an unknown object 35 minutes earlier. An initial single plain chest x-ray in the anteroposterior view shows a circular object in the esophagus. What is the next step in the management of this patient?

    Conservative management
    Lateral x-ray
    Serial x-rays
    Endoscopic retrieval
    Surgery

    The next step is a lateral x-ray because the mother does not know what the child swallowed. In this case, the need arises to differentiate between commonly ingested circular foreign bodies such as coins and corrosive disc batteries. This also helps to ascertain the position of the foreign body in the esophagus. Once a coin has been identified, conservative management can be employed. Serial x-rays would be taken to establish whether the coin has passed through the narrowest part of the gastrointestinal tract (the esophagus). If the coin remains in the esophagus, endoscopy must be considered within 24 hours after first presenting to the hospital for the object's removal in order to avoid the risk for esophageal pressure necrosis and perforation. Surgery is a very rare management option for an uncommon failure of endoscopic retrieval.
    A 21-year-old man with recently diagnosed schizophrenia comes to the emergency department with his parents. For the past hour he has been complaining of pain in his upper abdomen. He admits to swallowing coins. If the patient undergoes endoscopic retrieval of the coin, where would you expect it to be found in the gastrointestinal tract?

    Upper esophagus
    Middle esophagus
    Lower esophagus
    Gastroesophageal junction
    Pyloric sphincter

    Foreign objects most commonly become lodged at the narrowest part of the gastrointestinal tract, which is in the upper esophagus at the level of the thoracic inlet. The next most common site is the gastroesophageal junction. Once a foreign object enters the stomach, the chance of it being lodged anywhere along the rest of the gastrointestinal tract is relatively small. Rarely, sharp, long, or large objects can get stuck at the pylorus, the duodenal sweep, or at the ileocecal valve. Such a situation requires intervention.


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