Unknown Case of the Month #64 |
| Findings: AP and lateral films of the esophagus show a large filling defect in the distal one third of the esophagus with proximal dilation. Diagnosis: Esophageal Foreign Body (hot dog) Acute impaction of food in the esophagus is commonly encountered in the emergency department. The clinical presentation is usually straightforward and the diagnosis is easily confirmed with an esophagram, performed either with barium or a low osmolality, water-soluble contrast agent. In addition to establishing the diagnosis, potential causes for perforation should also be assessed, including: an underlying esophageal abnormality (diverticulum, stricture, carcinoma), the presence of a sharp foreign body, or duration of symptoms greater than 24 hours (possibility of superimposed mucosal ulceration). Endoscopic removal has been the traditional treatment of choice, after earlier attempts to digest the impacted meat with proteolytic enzymes resulted in several cases of perforation, mediastinitis and death. In the absence of a demonstrable underlying esophageal abnormality, a radiology treatment may be attempted using glucagon (esophageal relaxation), an effervescent agent (esophageal distention) and water (increased hydrostatic pressure). Contraindications to glucagon should be avoided, including, known drug sensitivity or clinically suspected insulinoma (release of insulin response to glucagon administration could rapidly decrease blood glucose) or pheochromocytoma (glucagon may stimulate the release of catecholamines). It is advisable to have personnel experienced with airway support available in case of an acute aspiration. In one recently reported series, 33 (69%) of 48 attempts were successful with this therapy. Recurrence should raise the possibility of an underlying esophageal abnormality. The differential diagnosis of esophageal strictures (the most common cause of dysphagia in their own right), includes: lower strictures due to acid and alkaline reflux esophagitis, achalasia, scleroderma, and Zollinger-Ellison syndrome and upper and middle strictures due to Barret esophagus, mediastinal radiation, prior ingestion of caustic substances, intramural diverticulosis, various inflammatory conditions and congenital stenosis. The latter may have a "ringed appearance", thought by some investigators to represent tracheobronchial rings, although others believe this is an acquired condition secondary to peptic reflux. Narrowings greater than 15 mm (barium tablets are typically 12mm) are more likely to cause problems as well as treatment failures, although the ultimate success of radiology therapy may be more dependent upon the size and texture of the ingested material causing the obstruction. References: Robbins MI, Shortsleeve MJ. Treatment of acute esophageal food impaction with glucagons, Holsinger JW Jr, Fuson RL, Sealy WC. Esophageal perforation following meat impaction Berrocal T, Torres I, Gutierrez J, Prieto C, Del Hoyo ML, Lamas M. Dr. Lawrence C. Swayne, Attending Back to Case of the Month Archive |