Esophageal foreign bodies in adults: systematic review of the literature

Where Did the Lox 10 Tip Go? A Silent Iatrogenic Foreign Body: Case Report

Esophageal foreign bodies (FBs) are a common medical emergency, often requiring prompt diagnosis and intervention to prevent severe complications. While sharp objects like bones are frequently encountered, iatrogenic foreign bodies remain rare. We present a unique case of an elderly patient who inadvertently swallowed the dislodged tip of a Lignocaine spray applicator during an ENT procedure. Despite being asymptomatic, imaging confirmed the foreign body in the lower esophagus, which was successfully retrieved via flexible endoscopy. Our case highlights the importance of thorough assessment and imaging when foreign body ingestion is suspected, even in asymptomatic individuals. It also highlights the importance of careful equipment inspection, early recognition of potential device malfunctions, and timely intervention to ensure patient safety.

Device Failure During Injection Medialization Laryngoplasty

OBJECTIVES

Injection medialization laryngoplasty is a commonly performed procedure for the management of glottic insufficiency. Among complications of this procedure is device failure, for which the literature is scarce. Our goal was to determine the prevalence of needle failure during injection laryngoplasty among members of the American Bronchoesophagological Association (ABEA).

METHODS

A questionnaire was designed and subsequently sent to members of ABEA via electronic mail. Responses were analyzed using descriptive statistics.

RESULTS

Twenty-four members (6.7%) completed the survey. Eighty three percent reported experience with needle failure; 59% of these were needle clogging, 22% needle twisting, and 19% needle tip fracture. Fifty-four percent of respondents reported needle failure during a percutaneous approach, and 48% reported using calcium hydroxyapatite during device failure. Twenty percent reported having to abort the procedure due to device failure. Twenty five percent of respondents experienced needle tip fracture that led to an airway or esophageal foreign body.

CONCLUSIONS

Needle failure during injection laryngoplasty was reported by most respondents. Most commonly this was due to clogging or twisting which was managed by replacing the needle but in 25% of cases was due to a broken tip that results in an aerodigestive tract foreign body and aborting of the procedure in most cases.

Insidious pericardial journey of an orthodontic metallic retainer wire

Ingestion of foreign bodies may be a frequent cause of painful dysphagia. We report the case of a metallic wire impacted in the oesophagus with potentially devastating consequences.

Migration of a Fish Bone From the Esophagus to the Thyroid Gland

Accidental swallowing of fish bone is one of the most common emergencies in the otolaryngology department. The impacted fish bones are usually found in the palatine tonsil, base of the tongue, valleculae, pyriform sinus, and esophagus, which can be successfully removed after a thorough examination. However, in some cases, the fish bone may penetrate into the neck soft tissue and migrate to extraluminal organs, causing infection, abscess formation, or rupture of vessels. In such cases, prompt recognition and immediate removal of the impacted fish bone are necessary. Herein, we report a rare case of a 60-year-old woman who had accidently swallowed a fish bone 10 days prior to visiting the outpatient department. The fiberoptic scope and head and neck computed tomography scans were obtained from the outpatient department. The fish bone was found to migrate from the upper esophagus to the left thyroid gland. First, a rigid esophageal endoscopy was performed in the operating room, but no obvious fish bone was noted over the esophagus. Finally, the fish bone was removed via exploratory cervicotomy with left-sided total lobectomy of the thyroid. The patient recovered after the operation, and there were no further complications during the 3 years of follow-up.

Adult Esophageal Foreign Bodies

This manuscript reviews and outlines the necessary tools to efficiently assess and manage an adult patient where an esophageal foreign body is suspected. It reviews the vulnerable populations and relevant diagnostics and provides a triage diagram to aid in timely intervention. Management with esophagoscopy is reviewed as well as potential complications that may arise. Lastly, to illustrate the concepts of this section, a case study is presented to highlight the salient points.

Rare Complications Following Laparoscopic Sleeve Gastrectomy

Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.

The Management of Esophageal Perforation: A Systematic Review

Esophageal perforation, a rare and serious condition, has seen a reduction in mortality from 30% to 15% over the last three decades due to advancements such as gastrointestinal stents, minimally invasive surgeries, and improved interventional radiology techniques. This review analyzes management strategies for esophageal perforation based on 14 English-language articles published from 2009 to 2024, primarily utilizing surveys and national database analyses. The management of esophageal perforation is complex, with challenges in diagnosis and treatment strategy. Despite surgery being the traditional treatment, the role of less invasive methods is growing. Effective management of esophageal perforation involves advanced imaging for diagnosis, hemodynamic stabilization, and a multidisciplinary approach to treatment, including surgical and non-surgical interventions. The evidence for different treatment outcomes remains limited, highlighting the need for comprehensive care involving thoracic surgery, interventional radiology, gastroenterology, and critical care in an intensive care unit setting.

Open surgery with a lateral neck approach in cases of foreign body impaction that penetrating the neck through the esophagus: a single-center experience

BACKGROUND

Because the cases are quite scarce, we aimed to review cases of foreign body impaction penetrating the neck through the esophagus to analyze the characteristics of these cases. The open surgery skills of the surgeon, the treatment procedure and the surgeons' experience in the rare diseases were analyzed.

METHODS

We collected and analyzed all cases from 2015-2020 in our hospital. Surgical skills and procedures for fasting and anti-infection treatment were reviewed retrospectively. Follow-up was telephone communication.

RESULTS

Our series included 15 cases. Tenderness in the pre-cervical site was a physical sign for screening. Thirteen cases underwent a lateral neck open surgery with the incision including the left side of neck and only two cases were incised from the right side of the neck. Pus was found 3 days after the impaction in one case, the shortest time observed in our series. The esophageal laceration was only sutured primarily in 5 cases (33.33%) among all fifteen cases. After sufficient drainage (average more than 9 days), antibiotic treatment and fasting (normally 2-3 weeks), patients gradually began to switch to solid foods from fluids after complete blood counts and confirmations from esophageal radiography result. No severe complications occurred, and all the patients have no swallowing dis-function and recovered well.

CONCLUSION

Surgery should be performed as soon as possible after impaction. Lateral neck approach surgery and the therapeutic procedure described in this article are safe and effective treatments.

Association between time from esophageal food impaction to endoscopy and adverse events

BACKGROUND AND AIMS

Guidelines recommend emergent or urgent EGD for esophageal food impaction (EFI), but data on how time to EGD impacts the risk of adverse events remain limited. We determined whether EFI-to-EGD time was associated with adverse events.

METHODS

In this retrospective cohort study of patients with endoscopically confirmed EFI, adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extraesophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Esophageal perforation and extraesophageal adverse events requiring intensive care unit admission were classified as serious adverse events. Baseline characteristics, event details, and procedural details were compared between patients with and without adverse events. Multivariable logistic regression was performed to assess for an association between EFI-to-EGD time and adverse events.

RESULTS

Of 188 patients with EFI, 22 (12%) had any adverse event and 2 (1%) had a serious adverse event. Patients with adverse events were older and more likely to have an esophageal motility disorder, to tolerate secretions at presentation, and to have a higher American Society of Anesthesiologists score. EFI-to-EGD time was similar in those with and without adverse events. On multivariable analysis, EFI-to-EGD time was not associated with adverse events (odds ratio, 1.00 [95% confidence interval, .97-1.04] for 1-hour increments; odds ratio, 1.03 [95% confidence interval, .86-1.24] for 6-hour increments). Results were similar after stratifying by eosinophilic esophagitis status and after adjusting for possible confounders.

CONCLUSIONS

Because the time from EFI to EGD is not associated with adverse events, emergent EGD for EFI may be unnecessary, and other considerations may determine EGD timing.

Varied Manifestations of Sharp Penetrating Foreign Bodies in the Aerodigestive Tract: Our Experience

Introduction Foreign body ingestion or aspiration is an emergency dealt by otorhinolaryngologists. It is most common among children and the geriatric population. It paves the way for critical morbidity when prompt treatment is not initiated. Therefore, in the absence of strong evidence to guide decision-making, all suspicious presentations of the ingested sharp foreign body need to be kept in mind while making a diagnosis. Hence, our study is aimed to document the varied manifestations of sharp penetrating foreign bodies in the aerodigestive tract. Materials and methods The medical records of 40 patients who presented with sharp foreign body ingestion/aspiration in the department of otorhinolaryngology in our centre from September 2012 to September 2022 were reviewed retrospectively. Results In all 40 patients, we were able to retrieve the foreign body as such without crushing or breaking it. In our study, the most common foreign body retrieved among middle-aged and elderly were chicken bone (22.5%) or fish bone (25%), and the most common foreign body following accidental ingestion in children were stapler pins (20%). Conclusion The findings of our study concluded that relevant clinical history, atypical presentation, and radiological imaging of sharp penetrating foreign bodies in the neck should be addressed with the utmost caution, as foreign bodies migrate to deep neck space and bronchus and can result in untoward complications. Hence, we need to be suspicious of the varied manifestation of aerodigestive tract foreign bodies for early diagnosis and prompt treatment.

A Rare Etiology of Esophageal Obstruction: Esophageal Clot Formation After Teeth Extraction

Esophageal obstruction represents an endoscopic emergency owing to the high mortality rate associated with complications, including perforation and airway compromise. While typically caused by food or foreign body ingestion, esophageal clot represents a rare etiology of obstruction. We present a case of esophageal obstruction in the context of an anastomotic stricture and chronic anticoagulation for atrial fibrillation caused by clot formation due to oral hemorrhage after dental extractions. Clot retrieval was accomplished via endoscopic suction, and balloon dilation of the anastomotic stricture was performed to prevent recurrence. Our case illustrates the importance of considering oral hemorrhage, therapeutic anticoagulation, and esophageal strictures as risk factors for esophageal obstruction due to clot formation in order to make a timely diagnosis and treatment of this potential endoscopic emergency.

Tracheobronchial tooth and dental prosthesis aspirations: 15 cases

BACKGROUND

Tracheobronchial foreign body is uncommon in adults. Among foreign body aspirations, tooth and dental prosthesis aspiration is a very rare condition. In the literature, dental aspiration is generally found as a case report and there is no single-center case series. In this study, we aimed to present our clinical experience in 15 cases with tooth and dental prosthesis aspiration.

METHODS

Data from 693 patients who presented to our hospital for foreign body aspiration between the years 2006 and 2022 were analyzed retrospectively. Fifteen cases who aspirated tooth and dental prostheses as foreign bodies were included in our study.

RESULTS

Foreign bodies were removed by rigid bronchoscopy in 12 (80%) cases and fiberoptic bronchoscopy in 2 (13.3%) cases. In one of our cases, foreign body was expected with cough.When evaluated in terms of foreign body, partial upper anterior tooth prosthesis in 5 (33.3%) cases, partial anterior lower tooth prosthesis in 2 (13.3%) cases, dental implant screw in 2 (13.3%) cases, lower molar crown in 1 (6.6%) case, lower jaw bridge prosthesis in 1(6.6%) case, upper jaw bridge prosthesis in 1(6.6%) case, broken tooth fragment in 1(6.6%) case, upper molar tooth crown coating in 1(6.6%) case and upper lateral incisor tooth in 1(6.6%) case were observed.

CONCLUSION

Dental aspirations can also occur in healthy adults. Anamnesis is the most important factor in diagnosis and diagnostic bronchoscopic procedures should be performed in cases where adequate anamnesis cannot be obtained.

Long-term retainment of a foreign body in the esophagus in an adult: a case report

Ingestion of a foreign body (FB) is a common emergency encountered in otorhinolaryngology. In most cases, FBs pass through the digestive tract spontaneously without any serious consequences, but some of them require nonsurgical interventions, and more severe cases require surgical interventions. The types of FBs ingested may differ in different countries and regions. In adults, bones, fish bones, and dental prostheses are most commonly found in the esophagus, and most of the FBs are retained in the esophagus less than 1 month. To the best of our knowledge, this is the first report of an unusual FB (a beer bottle cap) that was stuck in the upper esophagus for longer than 4 months. The main complaints of the patient were a sore throat and FB sensation, and an FB was diagnosed by a chest radiograph and computed tomography of the esophagus. He then had rigid endoscopic removal of the FB performed under anesthesia with propofol sedation. During a 3-month follow-up, the patient was asymptomatic and no esophageal stricture was observed. Impaction of FBs in the gastrointestinal tract can lead to severe adverse events. Therefore, early detection and timely management of FBs are important.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

Risk factors for the poor prognosis of Benign esophageal perforation: 8-year experience

BACKGROUND

Esophageal perforation (EP) has a high mortality rate and poor prognosis. This single-center retrospective study aims to analyze the related risk factors for benign EP.

METHODS

We retrospectively analyzed 135 patients with benign EP admitted to the First Affiliated Hospital of Nanchang University from January 2012 to December 2020. Univariate and multivariate logistic analysis were performed to estimate risk factors for prognosis of esophageal perforation patients.

RESULTS

There were 118 EP patients with foreign body ingestion and 17 patients with nonforeign body ingestion. Fish bones (78/118) were the most common foreign body and most of the nonforeign EPs were caused by spontaneous esophageal rupture (14/17). Foreign body perforations occurred mostly in the upper thoracic segment (70/118) and middle thoracic segment (31/118), and spontaneous esophageal ruptures occurred mostly in the lower thoracic segment (15/17). Fifteen patients (11.1%) died during hospitalization or within one month of discharge. Multivariable logistic regression analysis showed that high white blood cell (WBC) levels [odds ratio (OR) = 2.229, 95% confidential interval (CI): 0.776-6.403, P = 0.025], chest or mediastinal emphysema (OR = 7.609, 95% CI: 2.418-23.946, P = 0.001), and time to treatment > 72 h (OR = 3.407, 95% CI: 0.674-17.233, P = 0.018) were independent risk factors for poor prognosis.

CONCLUSION

Foreign body was the major reason for benign EP. High WBC level, chest or mediastinal emphysema and time to treatment > 72 h were risk factors for poor prognosis.

Dental Prosthesis in Esophagus: A Right Cervicotomic Approach

Foreign body ingestion in the upper digestive tract is a relatively common emergency. Less than 1% have to be treated surgically. We report the case of a 68-year-old man who ingested a dental prosthesis, probably during a seizure, and thus unknowingly, and presented two days later to the emergency department complaining of a mild dysphagia. A chest radiograph showed the presence of a removable dental prosthesis in the upper esophageal tract. The patient was brought to the operating room where a multidisciplinary equipe was assembled. Two attempts of retrieval with a flexible and a rigid endoscope failed because the removable dental prosthesis was stuck in the right pyriform sinus. Therefore, the surgeon performed an uncommon right cervicotomy and retrieved the foreign body through a right-side esophagotomy. The surgical approach depends on the nature and location of the foreign body. Urgent treatment is required whenever the patient develops dyspnea or dysphagia because of the high risk of inhalation and asphyxia. Removal of any esophageal foreign body has to be performed within 12-24 h. Repeated attempts to retrieve large dental prosthesis using an endoscope may result in esophageal perforation therefore when such risk of complication is too high, a surgical approach becomes inevitable. In our opinion, surgery remains the extrema ratio after a failed endoscopic retrieval attempt but can be lifesaving despite high risk of complications.

Foreign Body in the Cervical Oesophagus: A Case Report

BACKGROUND

Foreign bodies in the upper aerodigestive tract represent an uncommon cause of visits to emergency departments. In the majority of cases, foreign bodies do not go beyond the pharynx. They cause dyspnoea or pneumonia if they reach the tracheo-bronchial tree. If ingested, they will pass spontaneously through the gastrointestinal canal in the majority of cases. Nevertheless, especially in case of sharp-pointed or large objects, the foreign bodies can stop in the oesophagus. In case of dysphagia, stinging sensation and/or odynophagia occurring after eating a meal, a foreign body in the upper aerodigestive tract should be suspected. If not clinically visible, imaging is required.

CASE PRESENTATION

A 72-year-old woman presented to the Emergency Department with pharyngodynia, odynophagia, stinging, dysphagia, and sialorrhea for 12 hours. Her symptoms started after eating a meal with meat. The patient underwent a standard two-projection radiogram of the neck. The antero-posterior projection radiogram was unremarkable. The lateral projection radiogram showed 16 millimetres in maximum length radiopaque foreign body within the cervical oesophagus. The patient underwent transoral flexible oesophagoscopy under general anaesthesia, with successful removal of the foreign body (bony fragment). Her symptoms improved rapidly after the procedure, and the patient was discharged after 48 hours in good health.

CONCLUSION

A foreign body in the cervical oesophagus may lead to visceral perforation. Once suspected, every effort should be made to identify and remove the foreign body to avoid potentially catastrophic consequences. In some cases, imaging could be necessary to detect the foreign body.

Rigid versus flexible endoscopy for managing ingested foreign bodies-can we improve pathways?

PURPOSE

This study aims to evaluate management pathways, outcomes and safety of rigid endoscopy (RE) and flexible endoscopy (FE) for the treatment of impacted foreign bodies of the upper gastrointestinal tract (UGIT) in adults.

METHODS

Retrospective study, included all patients undergoing RE or FE for impacted UGIT foreign body over an 11-year-period.

RESULTS

A total of 144 patients were included (95 FE and 49 RE). FE were performed under local anaesthetic or sedation, and RE under GA. Success rate of FE and RE were 95.8% and 95.9% respectively. During FE an intra-procedural biopsy was performed in 45/95 (47.3%); with 26/95(27.4%) identifying mucosal pathology. Complications was significantly higher in patients having RE (40.8% versus 6.3%, p = .001).

CONCLUSION

FE and RE are effective for the therapeutic management of impacted UGIT foreign bodies. However, FE can be performed under LA and was associated with fewer complications, favouring FE where possible as a first line option.

Safety and Efficacy of Nonoperative Treatment in Esophageal Perforation Caused by Foreign Bodies

INTRODUCTION

Esophageal foreign bodies are often treated by endoscopy, but the treatment of esophageal perforation caused by foreign bodies remains controversial. The purpose of this study was to investigate the safety and efficacy of nonoperative treatment of esophageal perforation caused by foreign bodies.

METHODS

We retrospectively analyzed 270 patients admitted to our hospital for esophageal perforation caused by foreign bodies from January 2012 to December 2020, all of whom received nonoperative treatment.

RESULTS

The mean age of the patients was 56 ± 17 years, and fish bones were the most common type of foreign body. A total of 61.2% of the perforations were in the cervical esophagus. All patients received nonoperative treatment initially, and the foreign body removal rate using endoscopy reached 97%. The perforation healing rate reached 94.8%, whereas 3 patients (1.1%) died during hospitalization. The median (range) duration of hospitalization was 4 days (3-6). Multivariable analysis showed age ≥ 66 years (odds ratio [OR]: 2.196; 95% confidence interval [CI]: 1.232-3.916; P = 0.008), men (OR: 1.934; 95% CI: 1.152-3.246; P = 0.013), and time to treatment (OR: 1.126; 95% CI: 1.027-1.233; P = 0.011) were independent risk factors for infection, whereas the risk of infection was lower when the foreign body type was fish bone (OR: 0.557; 95% CI: 0.330-0.940; P = 0.028).

DISCUSSION

Nonoperative treatment is safe and effective for esophageal perforation caused by foreign bodies. Even if perforation is combined with infection, active nonoperative treatment can still achieve a good effect. Early intervention can effectively reduce the risk of infection and improve patient outcomes.

Pathophysiology of Dysphagia in Eosinophilic Esophagitis: Causes, Consequences, and Management

Eosinophilic esophagitis (EoE) is a leading cause of food bolus impaction in children and adults. The mechanism of dysphagia in EoE, particularly non-obstructive dysphagia, remains incompletely understood. While fibrostenotic processes appear to be critical in the development of dysphagia, somatosensory dysfunction and dysmotility also contribute. This review considers potential mechanisms of dysphagia and evaluates the utility of current and future treatment strategies in this context.

Emergency management of jujube pit esophageal impactions using rigid esophagoscopy in the aged

OBJECTIVE

To study the emergency management of esophageal jujube pit ingestion.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective study of 114 consecutive cases of jujube pits esophageal impaction during 3 months was performed.

RESULTS

One hundred and fourteen cases were confirmed as jujube pit esophageal impaction using contrast-enhanced radiography. All jujube pits were retrieved using rigid esophagoscopy under general anesthesia as outpatients, except one case where a direct laryngoscope was used. In four cases, esophageal perforation was found, the patients were treated with conservative measures, and none died.

CONCLUSION

Jujube pit esophageal impaction is characterized by a high incidence of perforation. The conservative management of cervical perforation is effective in this study. Rigid esophagoscopy under general anesthesia is safe for jujube pit esophageal impaction.

LEVEL OF EVIDENCE

4.

Use of a dissected intravenous giving set to assist large metal oesophageal foreign body removal in rigid oesophagoscopy

BACKGROUND

Oesophageal foreign body removal may be challenging. If a foreign body is sufficiently high risk and cannot be retrieved via oesophagoscopy, laparotomy may be required as the foreign body migrates distally.

OBJECTIVE

This paper presents the use of the plastic tubing from an intravenous giving set, combined with rigid oesophagoscopy grasping forceps, in order to improve purchase and obtain sufficient traction on a large, smooth, metallic distal oesophageal foreign body (knife).

RESULTS AND CONCLUSION

This method offers an option for removal of oesophageal foreign bodies that may be rendered challenging with traditional metal grasping forceps given the lack of purchase and traction afforded by a 'metal on metal' grip, potentially avoiding the need for open surgery.

Eosinophilic esophagitis: an interdisciplinary clinical problem

Eosinophilic esophagitis is a newly described entity of increasing incidence. Previously thought to be a variation of gastroesophageal reflux disease, now it becomes well known among gastroenterologists, allergologists, paediatricians and pathologists. Aetiology of the disease is strongly correlated with atopic and allergic disorders but exact pathogenesis and cellular mechanisms of inflammatory process in the esophagus are still unknown. Diagnostic criteria have been described but diagnostic tools are still in the research and improvement phase. Clinical manifestation varies considerably between age groups, which causes a delay in the course of diagnosis due to improperly recognized symptoms. Since eosinophilic esophagitis is a chronic disease without a tendency to be self-limiting, delayed diagnosis may lead to complications associated with oesophageal tissue remodelling. Some forms of treatment are approved and of great therapeutical value, nevertheless clinical trials of new medications provide new possibilities. Therefore, many questions regarding eosinophilic esophagitis arise and are still unanswered.

Retrospective Analysis of Esophageal Foreign Body Ingestion: Differences Among Weekday, Weekends, and Holidays

Purpose

Current data on the occurrence of EFBs in relation to different time periods are scant. The purpose of this study was to compare the occurrence, type and location of EFBs in people who presented at our center on weekdays, weekends and holidays.

Patients and Methods

A retrospective analysis of patients (n=1353) received rigid esophagoscopy for foreign body extraction under general anesthesia from January 2018 to 2020 December.

Results

The occurrence of EFB ingestion was significantly higher (p<0.05) on holidays (2.75/day) than on weekdays (0.91/day) and weekends (1.46/day). Patients were much older on holidays, with a mean age of 58.18 ± 17.34 years, than patients on weekdays (54.71 ± 16.71 years) and weekends (55.05 ± 17.36 years).

Conclusion

Our findings demonstrate that EFB ingestion is most likely to occur on weekends and holidays, and elderly patients should be advised to chewing slowly and eating non-nuclear jujube, especially during holidays, to minimize their risk.

Long-term Follow-up for Missed Cases of Eosinophilic Esophagitis in Children With Previous Foreign Body in the Esophagus

OBJECTIVES

A foreign body impacted in the esophagus could be a sign of eosinophilic esophagitis (EoE). Our aim was to investigate if children previously diagnosed with a foreign body in the esophagus had a missed diagnosis of EoE.

METHODS

In this population-based longitudinal study, all children (0-18 years) diagnosed with a foreign body in the esophagus in Stockholm, Sweden 2006 to 2016, were identified. In addition to a review of medical files, each family was contacted (n = 325) and asked standardized questions. Children with symptoms indicating EoE were offered esophagogastroduodenoscopy (EGD).

RESULTS

We found 325 pediatric cases of foreign body. Two hundred and seven (64%) underwent an endoscopy at the event, 3 of these had biopsies taken, whereby 2 were diagnosed with EoE. Six additional patients were diagnosed with EoE between the initial event and the study follow-up. Children with persisting symptoms suggestive of EoE at the follow-up (n = 21), were offered EGD whereof 7 accepted. Four new cases of EoE were found. Hence, 12 (3.7%) of the children with a previous foreign body, either spontaneously released or endoscopically removed, were diagnosed with EoE. In the structured interview, dysphagia, food impactions and drinking excessively with meals, as well as food allergies, were significantly more common in EoE patients.

CONCLUSIONS

Children with a foreign body in the esophagus are at risk of having EoE. Biopsies should be taken during foreign body removal and questions about swallowing problems and allergic diseases should be carefully explored also in children who do not need EGD because of spontaneous release.

Comparison of Endoscopy Alone with Surgery Converted from Endoscopy for the Removal of Esophageal Foreign Bodies in Adults: A Retrospective Study from a Single Center

Background

The impaction of an esophageal foreign body is an urgent situation requiring emergency intervention. This retrospective study from a single center in China aimed to compare endoscopy alone with surgery converted from endoscopy for the removal of esophageal foreign bodies in adults.

Material/Methods

A total of 252 patients with esophageal foreign bodies were divided into 3 groups based on the treatment received: endoscopy, surgery converted from endoscopy, or surgery only. Patients’ clinical and demographic data were retrospectively reviewed and analyzed.

Results

The diameter of the foreign bodies in patients treated by surgery converted from endoscopy was larger than that of those treated by simple endoscopy (5.2 cm vs 2.7 cm, P=0.0003). The cervical or upper thoracic esophagus was the most common site of foreign body impaction treated by surgery converted from endoscopy, while the foreign bodies removed by simple endoscopy were frequently lodged at the middle thoracic esophagus (P=0.021). Bone-related foreign bodies and dentures were most likely impacted in patients treated with surgery converted from endoscopy. The factors influencing the choice of treatment included foreign body maximal diameter and location.

Conclusions

Larger foreign bodies that were found in the cervical or upper thoracic esophagus were associated with failed endoscopic removal and required surgical removal. Irregularly shaped or sharp foreign bodies, including dentures and fishbones, required surgical removal. These findings may guide future decisions of first-line approaches for the removal of esophageal foreign bodies.

Migration of ingested sharp foreign body into the bronchus: a case report and review of the literature

Background

Foreign body ingestion is a common emergence in gastroenterology. Foreign bodies are most likely to be embedded in the esophagus. The sharp ones may penetrate the esophageal wall and lead to serious complications.

Case presentation

A 72-year-old Chinese female was admitted to our hospital with a 4-day history of retrosternal pain and a growing cough after eating fish. Chest computed tomography scan indicated that a high-density foreign body (a fish bone) penetrated through the esophageal wall and inserted into the left main bronchus. First, we used a rigid esophagoscope to explore the esophagus under general anesthesia. However, the foreign body was invisible in the side of the esophagus. Then, the fiberoptic bronchoscopy was performed. We divided the fish bone, which traversed the left main bronchus, into two segments under holmium laser and removed the foreign body successfully. The operation time was short and there were no complications. The patient was discharged 1 week postoperatively and was symptom free even under a liquid diet.

Conclusions

There are several challenges in the management of this rare condition. We applied the technique of interventional bronchoscopy to the management of esophageal foreign body flexibly in an emergency. A surgery was avoided, which was more invasive and costly.

Triple Thoracic Injury Caused by Foreign Body Ingestion: A New Approach for Managing an Unusual Case

Patient: Male, 31-year-old

Final Diagnosis: Esophageal perforation

Symptoms: Chest pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Esophageal Obstruction and Death in a Nonverbal Patient

BACKGROUND

There are more than 100,000 cases of esophageal foreign body in the United States each year. Most cases resolve spontaneously; however, complete esophageal obstruction is a medical emergency. Patients with developmental disabilities are at high risk, because a large percentage of this population is effected by dysphagia, pica, tooth loss, or impulsive swallowing. In some cases, the diagnosis of esophageal foreign body can be made clinically, with the typical presentation including coughing, inability to tolerate secretions, drooling, vomiting, and dysphagia. In other instances, imaging is needed to confirm the diagnosis.

CASE REPORT

A nonverbal adult patient with history of mental retardation and dysphagia presented to the emergency department (ED) after a choking episode with persistent coughing. An x-ray study of the chest showed mild opacity at the left lung base and she was discharged with antibiotics. She returned to the ED that day with worsening symptoms suggestive of aspiration pneumonia. A computed tomography scan of the chest revealed numerous cylindrical objects in the esophagus, later identified as crayons. At least 28 crayons were removed via 3 endoscopies. During this time, the patient developed aspiration pneumonia, respiratory distress, and septic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Delayed recognition of foreign body puts patients at risk for esophageal perforation, aspiration, airway compromise, infection, sepsis, and death. In nonverbal patients presenting with upper respiratory symptoms, it is especially important to consider esophageal foreign body in the differential diagnosis, because this group is high risk for missed diagnosis and complications secondary to the foreign body.

Esophageal emergencies: another important cause of acute chest pain

A variety of esophageal pathologies can present emergently with a chief complaint of acute chest pain. Computed tomography (CT) is often the first line of imaging in esophageal emergencies and provides useful information-even without an initial suspicion-when used in conjunction with other imaging modalities such as esophagography and direct visualization. We review various urgent and emergent esophageal disease entities which may manifest as acute chest pain, with an emphasis on CT and ancillary imaging appearances, while discussing management according to their emergency. Radiologists should be familiar with the imaging findings of these esophageal emergencies in order to provide an accurate diagnosis and recommend timely and appropriate management.

Unusual Foreign Body, a Spoon, in the Esophagus of a Middle-Aged Female: A Case Report and Review of the Literature

In adults, a large metal foreign body in the esophagus is rarely seen and is usually caused accidentally. Here, we have described an unusual case of foreign body (spoon) in the esophagus of an adult patient. A 48-year-old woman initially presented to the emergency department with marked dysphagia, drooling, and radiating pain to the chest. She had swallowed a spoon while trying to vomit because of feeling sick. Radiological images revealed a spoon stuck in the esophagus. The edge of the spoon was grabbed with forceps and safely extracted under hypnic anesthesia. No esophageal perforation was detected on evaluation with esophagography using Gastrografin on the next day. This case highlights an unusual situation in an adult patient showing long nonfood-type foreign body in the esophagus. It is important that an appropriate workup and removal of foreign body is performed according to the location and type.

Foreign body-related oesophageal perforation: a case series at a community-based hospital in Nepal

Oesophageal perforation is rare, associated with diagnostic dilemma, delayed presentation and high mortality rate (36%). Early diagnosis and treatment are crucial for a good outcome. Treatment is by non-operative methods (antibiotics, drainage of collections, oesophageal stenting and nutritional support) or by surgery, depending on the condition of the patient, timing of presentation and expertise. During a five-year period (2015-2019), we managed seven cases of oesophageal perforation due to a foreign body. Of them, 4 (57%) received operative intervention, while 3 (43%) were managed non-operatively. One postoperative mortality ensued; there was a mean hospital stay of 20 days.

Esophageal foreign bodies: observational cohort study and factors associated with recurrent impaction

BACKGROUND AND AIM

Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction.

METHODS

The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected.

RESULTS

Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P < 0.011). Surgical therapy was required in 4 patients (6.1%).

CONCLUSIONS

Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.

Retrospective chart review: seasonal variation in incidence of bolus impaction is maintained and statistically significant in subgroups with atopy and eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition with eosinophilic infiltration of the esophageal mucosa. The most prominent symptom is dysphagia, which may result in esophageal bolus impaction in need of surgical extraction. To investigate whether an earlier reported seasonal variation in esophageal bolus impaction present only in a subgroup of patients with EoE and atopic disorders could be confirmed in this larger study. A single center retrospective chart review of patients who were diagnosed with esophageal bolus impaction between January 2004 and December 2017 was performed. Clinical, epidemiological and histologic data were collected. A total of 755 cases with esophageal bolus impaction were reviewed. A significantly higher occurrence of soft bolus impaction in summer and fall was shown in cases with confirmed EoE and in cases with atopy but not in the nonatopic group or in the group with a negative biopsy result. EoE was found in 48% of biopsied patients. A significant seasonal variation in cases with esophageal bolus impaction and concomitant atopy and EoE is confirmed, but the study design does not allow a causative role of allergens to be established.

Retrospective observational analysis of esophageal foreign bodies: a novel characterization based on shape

This single-center retrospective study aims to investigate the clinical features of esophageal foreign bodies (EFBs) and determine the influence of EFB shapes on management and prognosis. A total of 427 patients aged 13 to 95 years with suspected EFB ingestion were enrolled between January 2013 and June 2018, 183 of whom were male. EFBs were divided into six shapes: pin (n = 161), sheet (n = 97), trident (n = 51), spindle (n = 66), irregular (n = 46), and sphere (n = 6). Spindle-shaped EFBs correlated with a significantly higher rate of perforation and severe complications (P < 0.001 and P = 0.021, respectively) than any other EFB shape, while sheet-shaped EFBs were linked to less severe complications (P = 0.006). The number of pressure points was provided to stratify the risk of poor prognosis for each shape. EFBs with only two pressure points (pin and spindle EFBs) required more advanced management strategies and were correlated with a higher number of patients suffering esophageal perforation (27.11%) and severe complications (12.44%) when compared with other shapes (χ² = 11.149 and P = 0.001; χ² = 5.901 and P = 0.015, respectively). Spindle shape was an independent risk factor for poor prognosis, and contributed a more clinical risk than the pin shape. In conclusion, clinical features, management, perforation rate, and severe complications differed based on EFB shape. The EFBs with two pressure points, especially the spindle-shaped EFBs, were more dangerous compared with those with more pressure points.

Management of Sharp-Pointed Esophageal Foreign-Body Impaction With Rigid Endoscopy: A Retrospective Study of 130 Adult Patients

OBJECTIVES

To propose a management algorithm for adult patients with sharp-pointed esophageal foreign-body impaction (EFBI) who have rigid endoscopy (RE) indications and to conduct a retrospective analysis of their data.

METHODS

All adult patients who received RE at the Department of Otorhinolaryngology in Beijing Shijitan Hospital between January 2017 and May 2019 were enrolled. The demographics, clinical characteristics, and management data were collected and analyzed.

RESULTS

A total of 130 patients were identified, 56.9% were female with median age 60 years. More than half (56.9%) of patients had foreign-body (FB) ingestion on holidays. The most frequent FBs were jujube pits (66.9%) and bones (23.8%). There is a significant female predominance in ingestion of jujube pits (65.5%, P = .005). The most common symptoms were odynophagia (49.2%) and sore throat (47.7%). The majority (96.8%) of FB founded were lodged at upper esophagus. In all, 74 patients were categorized as having mild complications and 54 having significant complications. Time interval from ingestion to presentation longer than 15 hours was an independent risk factor for significant complications, while esophagogram with barium as a protective factor.

CONCLUSIONS

Long-time interval from ingestion to presentation will lead to high risk of significant complications. Computed tomography should be a prioritized imaging method for all patients suspected with EFBI, and multidisciplinary collaboration is recommended. Besides, mass education on eating habits is necessary.

Clinical Analysis of Denture Impaction in the Esophagus of Adults

Denture impacted in the esophagus of adults has been a complex foreign body for otolaryngologists. We reviewed clinical characteristics, diagnosis, and treatment of these patients and evaluated computed tomography (CT) scans to identify a better method of dealing with such tricky situations. Twenty-nine patients who underwent rigid esophagoscopy were included in this retrospective study conducted at the University hospital. The patients underwent preoperative tests and examinations, including complete blood count, blood type and coagulation, electrocardiogram, and CT. The commonest symptoms were retrosternal pain, dysphagia, and odynophagia. Duration of the foreign body impacted within 24 h was 65.5%. CT findings revealed that 4 of 24 cases had complications in the upper esophagus, with 3 of the 4 cases in the mid-esophagus and 1 in the lower esophagus. Complications were related to the duration and location of the obstruction (P < 0.05). The location and complications based on CT findings were coherent with rigid esophagoscopy findings. Denture impaction in the esophagus can be fatal. Early intervention is crucial for prognosis. CT is used for diagnosing and guiding doctors in managing. The commonest location of impacted dentures was the upper esophagus with a lower incidence of complications. The incidence of an impacted denture in the mid-esophagus was low but with a high risk of complications. The incidence of an impacted denture in the lower esophagus was rare. Surgery and proper treatment ensure a good prognosis.

A fish bone induced aortic arch pseudoaneurysm in a male patient: A case report

RATIONALE

Esophageal foreign body is a commonly seen in China. However, pseudoaneurysm of the aortic arch caused by ingestion of fish bones is a rare, life-threatening condition.

PATIENT CONCERNS

A 71-year-old male was admitted to the Ear, Nose, and Throat department with a 4-day history of chest pain after eating fish.

DIAGNOSES

After taking out the fish bone by rigid endoscopy, magnetic resonance imaging and computerized tomography angiography (CTA) scans revealed the presence of an aortic arch pseudoaneurysm, which was likely caused by the fish bone.

INTERVENTIONS

A successful endovascular graft exclusion surgery was performed to block the aorta ulcer.

OUTCOMES

The patient recovered and was discharged 20 days after hospitalization. The patient was healthy and had no fever or chest pain 4 months after discharge from the hospital.

LESSONS

Esophageal foreign bodies may lead to life-threatening impairment of the aorta or other big arteries. When esophageal foreign bodies puncture the esophageal wall, especially in the second stenosis of the esophagus, an enhanced-contrast computed tomography scan or a CTA scan may be necessary to exclude any potential impairment of the arteries.

Esophageal emergencies: WSES guidelines

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions.

OBJECTIVE OF THE REVIEW

This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions.

DISCUSSION

Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes.

CONCLUSIONS

This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.