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A 21-Year-Old Man With an Interesting Radiologic Finding

Discussion in 'Radiology' started by Hadeel Abdelkariem, May 26, 2018.

  1. Hadeel Abdelkariem

    Hadeel Abdelkariem Bronze Member

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    A 21-Year-Old Man With an Interesting Radiologic Finding

    Background

    A 21-year-old white man presents to the emergency department with a 10-hour history of epigastric pain that is radiating to the chest. The pain is constant, localized, and sharp in nature. He was at a party the previous night and admits to drinking alcoholic beverages but denies any illicit drug use. There is no associated nausea, vomiting, or indigestion, and he denies ever having suffered from this pain in the past. The patient gives no history of shortness of breath, palpitations, or syncope. There is no history of trauma to the epigastrium, and the patient does not remember anything that may be causing his symptoms. His past medical history is significant for an appendectomy 9 years ago and surgery for a deviated nasal septum 11 months ago. He is not currently on any regular medication. There is no history of allergies. His family history is negative for any cardiac or abdominal pathology. He smokes approximately 1 pack of cigarettes a day and admits to binge-drinking alcohol at weekend parties.

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    Physical Examination and Workup
    On examination, he appears to be alert, comfortable, and in no acute distress. He is well oriented to person, time, and place. His vital signs reveal a heart rate of 76 bpm, a respiratory rate of 18 breaths/min, and an O2 saturation of 97% on room air. His temperature is normal. His respiratory and cardiovascular examinations reveal no abnormal findings. The abdominal examination reveals no abnormal findings on inspection, except for a well-healed appendectomy scar; otherwise, the abdomen is scaphoid and without any discoloration, bruises, or visible abnormalities. Palpation reveals a slightly tender but otherwise soft epigastrium, with positive bowel sounds and no evidence of guarding or rebound tenderness. No masses or organomegaly are appreciated, and the abdomen is resonant to percussion, with the absence of a fluid wave or shifting dullness. The spleen and liver margins are normal and the kidneys are not palpable. Neurologic examination is grossly normal with equal power, tone, and bulk in both upper and lower extremities bilaterally, normal reflexes, and intact cranial nerves. His mental status exam is normal.

    Laboratory investigations reveal a hemoglobin count of 16.9 g/dL (169 g/L) and a white blood cell count of 7.8 × 103/μL (7.8 × 109/L). Urea and electrolytes are within normal limits, and there is no derangement of liver function. Serum amylase is normal. A chest x-ray shows clear lung fields, a normal heart size, and no evidence of air under the diaphragm; however, the chest and abdominal x-rays do reveal a radio-opaque shadow in the central lower chest/epigastrium region. Electrocardiography shows a sinus rhythm with no evidence of ischemic changes. The patient is instructed to take nothing orally and is placed on intravenous fluids. His symptoms are persistent, and a repeat chest and abdominal x-ray at 12 hours postadmission shows that the previously seen shadow has not changed position. The decision to intervene endoscopically is made.

    Discussion
    In this case, the chest and upper abdominal x-rays revealed that the patient had ingested a foreign body, which appeared to be lodged at the gastroesophageal junction. There was no radiologic or clinical evidence of air in the mediastinum or under the diaphragm, which ruled out an upper gastrointestinal perforation. The patient admitted to uncapping the bottles of alcoholic beverages with his teeth. He had accidently swallowed one such metallic bottle cap that, having impacted at the gastroesophageal junction, was responsible for his symptoms. The patient's own inebriation probably caused him to swallow the foreign body and was also the reason why he could not remember swallowing it. The patient denied any recent problems with swallowing solids or liquids, but he had not tried ingesting any solid food since the occurrence of the incident. A common symptom of total luminal obstruction is the inability to swallow one's own secretions. This was not the case here, and presumably some fluids were able to bypass the obstruction.

    Gastrointestinal foreign objects are either ingested (intentionally or accidently) or inserted rectally. They are encountered in all age groups but are more commonly seen in children between 6 months and 6 years of age.[Disc batteries are especially dangerous if ingested because they can cause caustic injury and quickly result in tissue necrosis and esophageal perforation. Intentional gastrointestinal foreign-body ingestion and insertion are more common than accidental occurrence in the adult population.

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    The diagnosis is usually made on the basis of the patient history and appropriate imaging; however, making the diagnosis can be difficult because the majority of patients who ingest foreign objects are either children or those in whom a proper history-taking would prove challenging (such as psychiatric patients or intoxicated patients). These patients may only present after the onset of symptoms such as choking, pain, refusal to eat, vomiting, wheezing, or respiratory distress.Peritonitis secondary to perforation of peritoneum. In the previously mentioned study, 87% of foreign objects were identified on plain x-ray.[puncture of the esophagus and/or aspiration on withdrawal. Failure of endoscopic removal usually means that the foreign body in question is a bone, with 76.5% of cases being fish bone,esophageal stricture, achalasia, esophageal diverticula, and eosinophilic esophagitis are common pathologies that are found at follow-up endoscopy.

    An American study concluded that adopting a conservative approach in the asymptomatic patient allowed spontaneous passage of nearly all swallowed foreign objects.(esophagogastroduodenoscopy) was performed to retrieve the bottle cap within 24 hours of the patient presenting to the ED. The metallic bottle cap was visualized at the gastroesophageal junction, and it was pushed down into the gastric cardia before retrieval. There was no other endoscopic abnormality of the upper gastrointestinal tract apart from associated gastritis. Initial attempts at retrieval of the bottle cap with the large biopsy forceps failed because the cap dropped back into the stomach upon reaching into the gastroesophageal junction. It was successfully removed with a basket net. The patient was later discharged from the hospital and warned about the dangers of uncapping bottles with his teeth.

    References
    1. Eisen GM, Baron TH, Dominitz JA, et al; American Society for Gastrointestinal Endoscopy. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55:802-806.

    2. Ayantunde AA, Oke T. A review of gastrointestinal foreign bodies. Int J Clin Pract. 2006;60:735-739.

    3. Dehghani N, Ludemann J. Ingested foreign bodies in children: BC children's hospital emergency room protocol. BC Medical Journal. Available at: www.bcmj.org/ingested-foreign-bodies-children-bc-children-s-hospital-emergency-room-protocol Accessed June 15, 2010.

    4. Block B, Schachschal G, Schmidt H. Endoscopy of the Upper GI Tract : A Training Manual. Tr by Telger TC. New York, NY: Thieme; 2004.

    5. Zhang S, Cui Y, Gong X, Gu F, Chen M, Zhong B. Endoscopic management of foreign bodies in the upper gastrointestinal tract in South China: a retrospective study of 561 cases. Dig Dis Sci. 2010;55:1305-1312.

    6. Weiland ST, Schurr MJ. Conservative management of ingested foreign bodies. J Gastrointest Surg. 2002;6:496-500.

    7. Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc. 1983;29:208-210.

    8. Triadafilopoulos G, Saltzman JR, Travis AC. Foreign bodies in the esophagus in adults. UpToDate. Available at: http://www.uptodate.com/patients/content/topic.do?topicKey=~f.FtEZAis9ZyM Accessed September 13, 2010.

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