Abstract

      Esophageal perforation and aortoesophageal fistulas are potentially life-threatening conditions requiring early recognition and repair. After thoracic aorta aneurysms, ingested foreign bodies are the second most frequent cause of aortoesophageal fistula. We present the case of a 63-year old man who presented to the emergency department (ED) with chest pain that began with a foreign body sensation after eating meat three days earlier. Physical examination was normal, but his chest x-ray revealed a wide mediastinum. Computed tomography (CT) of the thorax showed a foreign body in the subcarinal space and air in the mediastinum. With a pre-operative diagnosis of esophageal perforation, the patient was taken to the operation room. The chest surgeons found the foreign body to be a bone which extended to, and perforated, the aorta. It was impossible to save the patient. The triad of midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptomfree interval has been termed Chiari’s triad which is seen among aortoesophageal fistula patients. Patients coming to the ED with a complaint of chest pain, hemoptysis, hematemesis and history of foreign body ingestion must be evaluated carefully; aortoesophageal fistula must be recognized and treated early.

Key Words: Aortoesophageal fistula, chest pain, esophageal foreign body.

Introduction

      Esophageal perforation and aortoesophageal fistulas are potentially life-threatening conditions that must be identified and treated early to minimize morbidity and mortality (1, 2). An aortoesophageal fistula occurs rarely as a complication of the ingestion of a foreign body, most of which are food boluses and bones in adolescents and adults (3). Complicated foreign bodies that result in esophageal perforation and vascular injury are best managed surgically, not endoscopically (4).
We present a patient who came to the emergency department (ED) because of chest pain and blood coming from his mouth, three days after eating meat and feeling a foreign body sensation in his chest..


Case Report


       A 63-year old male presented to the ED with complaints of chest and back pain and blood coming from his mouth. Three days prior to his visit, while eating meat, he noticed the sudden onset of pain from his pharynx and to his stomach after swallowing. He thought that he had swallowed a bone. He continued to have mild chest pain for the next two days, but on the third day he also noticed some blood in his mouth after he coughed. He denied shortness of breath but had chest pain which increased with breathing and radiated to the back. Vital signs were: blood pressure 100/80 mmHg; pulse 105 beats/minute; respiratory rate 24/minute, axillary temperature 36° C; and oxygen saturation 93%. A little blood was seen around the teeth during the oral inspection. Speech was normal, and crepitance was absent when palpating the neck and thoracic cage. Lung sounds were normal except for rales at the right base. Abdominal exam was normal. Electrocardiography (ECG) showed sinus tachycardia and early repolarization in the inferolateral leads. Leukocyte count was 20,000/µL, Hemoglobin 14.4 g/dL, platelet 219,000/µL, glucose 138 mg/dL, blood urea nitrogen 38 mg/dL, creatinine 1.2mg/dL, Na+ 138 mmol/L, K+ 4.2 mmol/L, Aspartate aminotransferase (AST) 39 U/L, Alanine aminotransferase (ALT) 44 U/L, Creatine kinase (CK) 355 U/L, Creatine kinase- MB (CK-MB) 19 U/L, Protrombin time (PT) 22 seconds, Partial thromboplastin time (PTT) 31 seconds, and troponin was negative. Although PT was high the patient denied using any medication for this. His chest x-ray showed a para-cardiac non-homogenous infiltrate and a wide mediastinum (Figure 1).

The emergency physician considered aortic dissection as an etiology of the wide mediastinum and ordered a CT of the thorax. On the contrast CT, air was noted in the wide mediastinum, and a 3x2x1 cm sharp-edged density was seen in the subcarinal area (Figure 2 ).
 

He was taken to the operating room by the general surgeons 4 hours after ED arrival with similar vital signs to those he had upon arrival. Based on the CT result, the bone was thought to be lodged in the wall of the esophagus but during the operation the piece of bone was seen to extend from the esophagus into the aorta (Figure 3).
 

When the bone was removed, massive bleeding from the aorta occurred, which was impossible to control. Resuscitative efforts were unsuccessful and the patient died on the operating table..
 

Discussion


        Although foreign bodies in the esophagus are uncommon causes of esophageal perforation, this life-threatening condition requires early recognition and repair to prevent mediastinitis and death (4,5). Spontaneous esophageal perforation accounts for only 15% of cases, with iatrogenic injuries accounting for the remainder (1). Adults commonly tend to have pieces of meat and bones act as impacted foreign bodies, but morsels of other foods, coins, pins, needles, dentures, stones, watch batteries, toys and pressthrough packages can become impacted as well (6,7,8). Although most esophageal foreign bodies can be dislodged or removed in the emergency department or endoscopy suite, 2% of patients need surgical intervention (3).
Patients with upper esophageal perforation usually experience neck or chest pain, dysphagia, respiratory distress, fever, odynophagia and aphonia. Patients with perforation of the lower esophagus may show symptoms of abdominal pain, pneumothorax, hydropneumothorax and pneumomediastinum (1). Impacted foreign bodies in the esophagus can easily cause mucosal ulceration, inflammation, or even infections, and can also result in various fatal complications such as para- or retro-esophageal abscess, mediastinitis, empyema, perforation or even aortoesophageal fistula (6).
Over 90% of spontaneous esophageal ruptures occur in the distal esophagus (9). Temporary bleeding from the respiratory and digestive tracts is an important signal and may be crucial in the diagnosis of esophageal perforation and small vessel injury by ingested bone fragments (10). Aortoesophageal fistula is a rare but usually fatal cause of upper gastrointestinal bleeding (11). Although the most common etiology is thoracic aorta aneurysm, an esophageal foreign body is the second most common mechanism for the development of an aortoesophageal fistula. A typical patient presents with a history of chest pain, followed by arterial hematemesis (12). The triad of midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval has been termed ‘Chiari’s triad’ (13). Diagnostic tests used to confirm the presence of an aortoesophageal fistula all have limitations. Barium esophagrams have a low sensitivity. CT of the chest is 100% sensitive and 93% specific for signs of esophageal perforation: mediastinal air, extraluminal contrast, or fluid collections or abscesses adjacent to the esophagus. Although endoscopy of the upper gastrointestinal tract may reveal the fistula, many believe aortography to be the best procedure for demonstrating the aortoesophageal fistula. (13).
Esophageal foreign bodies should be considered in the routine differential diagnosis of chest pain. The case presentations of two patients with chest pain who had extensive work-ups to rule out myocardial ischemia were recently published; both were found to have esophageal foreign bodies as the cause of their symptoms, late in their clinical course (14).
Most esophageal foreign bodies are removed endoscopically, which offers the advantage of direct examination and evaluation of any esophageal damage inflicted by the foreign body, and the opportunity to search for and remove multiple foreign bodies if present (6). In the literature, other methods for removal have been described: removal by Foley catheter (with or without fluoroscopy), advancement into the stomach with a bougie, dissolution with papain or carbonated acidic soft drinks, glucagon, and removal using a magnet (6).
Treatment of esophageal perforation depends on the etiology, site and size of perforation, the time elapsed between perforation and diagnosis, underlying esophageal disease and the overall health status of the patient (15). Impacted sharp foreign bodies in the esophagus can be very difficult to manage. When attempts are made to remove such objects inappropriately, life-threatening complications such as perforation can occur (7). Perforation of the upper esophageal wall by ingested bones can cause sudden death.

Conclusion


        Patients presenting to the emergency department with complaints of chest pain, s, hematemesis and history of foreign body ingestion must be evaluated carefully. Esophageal perforation, mediastinitis, and/or aorto-esophageal fistula must be recognized and treated early. Emergency physicians must keep aorto-esophageal fistula high on his/her list of differential diagnoses if a patient with a history consistent with impacted esophageal foreign body presents to the ED with chest pain and upper gastrointestinal hemorrhage..

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