Images Dx

A meal to remember

Copyright © 2009 Society of Hospital Medicine

A previously healthy 50‐year‐old man was eating a meal of rigatoni and shrimp at his favorite San Francisco restaurant when he suddenly developed severe pain in his throat followed a short time later by pleuritic chest pain localized to the anterior right chest. He completed his meal and then sought medical attention in the Emergency Department. He was in mild distress secondary to pain but his physical examination was otherwise unremarkable. His laboratory studies showed a white blood cell count of 15,300/mm3 with 86% neutrophils. A chest X‐ray, electrocardiogram, cardiac enzymes, and ventilation/perfusion scan were all normal. Because there was suspicion of an ingested foreign body, an abdominal radiograph was obtained which revealed a 2‐cm trapezoidal foreign body in the right lower quadrant (Figure 1; arrow). A chest computed tomography (CT) scan revealed air in the mediastinum consistent with esophageal perforation (Figure 2). One day after admission a Hypaque esophagram showed trauma to the posterior cervical region of the esophagus, but no leak of contrast material into the mediastinum. The patient was managed conservatively with intravenous (IV) antibiotics and nothing by mouth. Stools were screened and 48 hours after admission the patient (painlessly) passed a piece of glass with a very sharp point (Figure 3) correlating in size and shape to the foreign body seen on the previous abdominal radiograph. The glass had apparently fallen into the patient's restaurant meal the night of admission. The patient did well and was discharged 6 days after admission. He asked the manager of his favorite restaurant to reimburse him the $200 copayment required for hospitalization required under his Preferred Provider Plan; the request was immediately honored.

Figure 1

Abdominal radiograph with arrow pointing to trapezoidal foreign body.

Figure 2

CT scan of chest showing air in mediastinum adjacent to trachea due to esophageal perforation.

Figure 3

Piece of glass recovered in patient's stool.

Esophageal perforation is an emergency because of its high mortality rate. The most frequent cause is iatrogenic with instrumentation from endoscopic procedures. Other causes include foreign body ingestion (as in this case), trauma, operative injury, and tumor.1 Aggressive surgical intervention vs. conservative nonsurgical management remains a controversial topic.2 Early‐contained perforations can be managed successfully by limiting oral intake and giving parenteral antibiotics.3, 4 Any signs of sepsis, deterioration in the patient's condition, or uncontained rupture warrants immediate surgical intervention.14

References

   Comments ()