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An unusual sharp foreign body in the esophagus and its removal
An unusual sharp foreign body in the esophagus and its removal SHELLY K. CHADHA,
MS,
S. GOPALAKRISHNAN,
MS, DLO,
and N. GOPINATH,
A lthough foreign bodies in the esophagus are a commonly encountered clinical entity in the dayto-day practice of otolaryngologists, they are uncommon in adults. We present here a case of a woman with ingestion of a razor blade that remained in situ for 1 month, after which it was removed endoscopically. CASE REPORT An 18-year-old woman presented to the emergency department with complaints of epigastric pain, hematemesis, and melena for the past month. While providing a detailed history, she admitted to having ingested a razor blade with suicidal intent 1 month earlier. On examination, the patient was found to be pale but well hydrated. There were no abnormal respiratory signs. The abdomen was soft and nontender with no organomegaly. A radiograph of the chest confirmed the presence of a radiopaque foreign body at the midthoracic level (Fig 1). A psychiatry referral revealed that the patient was a known depressive who was already under treatment for psychosis. Esophagoscopy was carried out after the relevant hematologic investigations were performed. Under general anesthesia, a rigid esophagoscope was passed and the foreign body was visualized at approximately 26 to 27 cm from the upper incisors. The edges of the razor blade were impacted into the posterior wall of the esophagus at that level. With the help of a crocodile forceps, the proximal end of the foreign body was held and gently disimpacted. Using extreme care and under constant vision, the proximal attachment of the 2 halves of the blade was broken in the center, From the Department of Ear, Nose, and Throat, JIPMER, Pondicherry. Reprint requests: Shelly K. Chadha, MS, C-211, Nirman Vihar, Delhi, India; e-mail, drshellychadha@rediffmail. com. Otolaryngol Head Neck Surg 2003;128:766-8. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00161-X 766
MBBS,
Pondicherry, India
allowing the 2 parts to be gently folded up. Alternately releasing the sharp edges from the walls and gently advancing the scope, the entire length of the blade was brought within the lumen of the scope. The esophagoscope was then withdrawn along with the foreign body. Repeat esophagoscopic procedure revealed mild oozing from the site of impaction, which subsided spontaneously. A nasogastric tube was inserted prophylactically, and the patient was kept without oral intake for the first 2 days. Postoperative antibiotics were administered for 5 days. Her postoperative course was uneventful, and the patient was discharged at the end of one week. However, she continues to undergo treatment in the psychiatry department of our hospital. DISCUSSION Most of the patients presenting to the emergency department with foreign body ingestion are in the pediatric age group,1 although, adults are not exempt from this clinical entity. Adults who are most prone to the ingestion or impaction of a foreign body2 are those with esophageal strictures, psychologically unbalanced individuals, alcoholics, and prisoners. Our case fits into the second category of patients; however, her mode of presentation was unusual. There were no complaints of dysphagia, pain, foreign body sensation, or respiratory symptoms. Instead, she presented with a history suggestive of gastric erosion along with hematemesis and melena. Among the wide variety of substances that have been removed from the esophagus over the years, sharp foreign bodies such as safety pins, bones, and blades present a challenge to the endoscopist. To ensure uneventful removal of the sharp, linear objects, Jackson3 devised the method of endogastric version. This could be applied to pointed foreign bodies such as safety pins that had been lodged with the pointed end facing up. Another described technique is the point-sheathed method.4 Here, the pointed end is brought into the lumen of the scope and withdrawn in toto, safely covered by the walls of the scope. Witzel et al5
Otolaryngology– Head and Neck Surgery Volume 128 Number 5
CHADHA et al
767
Fig 1. (A) Radiopaque foreign body in the midthoracic region (arrow). (B) Folded blade being ensheathed by the esophagoscope. (C) The extracted foreign body.
removed 6 half-blades from the stomach of a patient by using used a fiberoptic endoscope sheathed with plastic tubing to safely extract the blades. The technique we used for the removal of the razor blade was an adaptation of the point-
sheathed method. Both the edges and the entire length of the foreign body were sharp and hence potentially dangerous. Therefore, the entire foreign body after disimpaction was brought into the lumen of the esophagoscope, thereby ensuring
768 CHADHA et al
complete ensheathment of the sharp edges. It was then withdrawn along with its covering endoscope. In this manner, a potentially fatal consequence of this rare, sharp foreign body was averted. REFERENCES
1. Sabamurthy V, Ramajancyala P, Ramachary V. Foreign bodies in food and air passages. Ind J Otolaryngol 1971; 23:84-7.
Otolaryngology– Head and Neck Surgery May 2003
2. Vizzcarondo FJ, Brady PG, Nord HJ. Foreign bodies in the upper gastrointestinal tract. Gastrointest Endosc 1983;29: 208-10. 3. Jackson C. Esophagoscopic removal of open safety pins by new method. Laryngoscope 1910;20:446. 4. Jackson C, Jackson CL. Diseases of the air and food passages of foreign body origin. Philadelphia: WB Saunders; 1936. Appendix p.1. 5. Witzel L, Schuerer V, Muhlemann A, et al. Removal of razor blades from stomach with fibreoptic endoscope. Br Med J 1974;2:539-41.
MS,
S. GOPALAKRISHNAN,
MS, DLO,
and N. GOPINATH,
A lthough foreign bodies in the esophagus are a commonly encountered clinical entity in the dayto-day practice of otolaryngologists, they are uncommon in adults. We present here a case of a woman with ingestion of a razor blade that remained in situ for 1 month, after which it was removed endoscopically. CASE REPORT An 18-year-old woman presented to the emergency department with complaints of epigastric pain, hematemesis, and melena for the past month. While providing a detailed history, she admitted to having ingested a razor blade with suicidal intent 1 month earlier. On examination, the patient was found to be pale but well hydrated. There were no abnormal respiratory signs. The abdomen was soft and nontender with no organomegaly. A radiograph of the chest confirmed the presence of a radiopaque foreign body at the midthoracic level (Fig 1). A psychiatry referral revealed that the patient was a known depressive who was already under treatment for psychosis. Esophagoscopy was carried out after the relevant hematologic investigations were performed. Under general anesthesia, a rigid esophagoscope was passed and the foreign body was visualized at approximately 26 to 27 cm from the upper incisors. The edges of the razor blade were impacted into the posterior wall of the esophagus at that level. With the help of a crocodile forceps, the proximal end of the foreign body was held and gently disimpacted. Using extreme care and under constant vision, the proximal attachment of the 2 halves of the blade was broken in the center, From the Department of Ear, Nose, and Throat, JIPMER, Pondicherry. Reprint requests: Shelly K. Chadha, MS, C-211, Nirman Vihar, Delhi, India; e-mail, drshellychadha@rediffmail. com. Otolaryngol Head Neck Surg 2003;128:766-8. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00161-X 766
MBBS,
Pondicherry, India
allowing the 2 parts to be gently folded up. Alternately releasing the sharp edges from the walls and gently advancing the scope, the entire length of the blade was brought within the lumen of the scope. The esophagoscope was then withdrawn along with the foreign body. Repeat esophagoscopic procedure revealed mild oozing from the site of impaction, which subsided spontaneously. A nasogastric tube was inserted prophylactically, and the patient was kept without oral intake for the first 2 days. Postoperative antibiotics were administered for 5 days. Her postoperative course was uneventful, and the patient was discharged at the end of one week. However, she continues to undergo treatment in the psychiatry department of our hospital. DISCUSSION Most of the patients presenting to the emergency department with foreign body ingestion are in the pediatric age group,1 although, adults are not exempt from this clinical entity. Adults who are most prone to the ingestion or impaction of a foreign body2 are those with esophageal strictures, psychologically unbalanced individuals, alcoholics, and prisoners. Our case fits into the second category of patients; however, her mode of presentation was unusual. There were no complaints of dysphagia, pain, foreign body sensation, or respiratory symptoms. Instead, she presented with a history suggestive of gastric erosion along with hematemesis and melena. Among the wide variety of substances that have been removed from the esophagus over the years, sharp foreign bodies such as safety pins, bones, and blades present a challenge to the endoscopist. To ensure uneventful removal of the sharp, linear objects, Jackson3 devised the method of endogastric version. This could be applied to pointed foreign bodies such as safety pins that had been lodged with the pointed end facing up. Another described technique is the point-sheathed method.4 Here, the pointed end is brought into the lumen of the scope and withdrawn in toto, safely covered by the walls of the scope. Witzel et al5
Otolaryngology– Head and Neck Surgery Volume 128 Number 5
CHADHA et al
767
Fig 1. (A) Radiopaque foreign body in the midthoracic region (arrow). (B) Folded blade being ensheathed by the esophagoscope. (C) The extracted foreign body.
removed 6 half-blades from the stomach of a patient by using used a fiberoptic endoscope sheathed with plastic tubing to safely extract the blades. The technique we used for the removal of the razor blade was an adaptation of the point-
sheathed method. Both the edges and the entire length of the foreign body were sharp and hence potentially dangerous. Therefore, the entire foreign body after disimpaction was brought into the lumen of the esophagoscope, thereby ensuring
768 CHADHA et al
complete ensheathment of the sharp edges. It was then withdrawn along with its covering endoscope. In this manner, a potentially fatal consequence of this rare, sharp foreign body was averted. REFERENCES
1. Sabamurthy V, Ramajancyala P, Ramachary V. Foreign bodies in food and air passages. Ind J Otolaryngol 1971; 23:84-7.
Otolaryngology– Head and Neck Surgery May 2003
2. Vizzcarondo FJ, Brady PG, Nord HJ. Foreign bodies in the upper gastrointestinal tract. Gastrointest Endosc 1983;29: 208-10. 3. Jackson C. Esophagoscopic removal of open safety pins by new method. Laryngoscope 1910;20:446. 4. Jackson C, Jackson CL. Diseases of the air and food passages of foreign body origin. Philadelphia: WB Saunders; 1936. Appendix p.1. 5. Witzel L, Schuerer V, Muhlemann A, et al. Removal of razor blades from stomach with fibreoptic endoscope. Br Med J 1974;2:539-41.