University of Virginia Digestive Health Center Charlottesville, VA, United States
Mark J. Radlinski, MD1, Benjamin Robey, MD2, Bryan Sauer, MD2, Daniel Strand, MD2 1University of Virginia Digestive Health Center, Charlottesville, VA; 2University of Virginia, Charlottesville, VA
Introduction: We present a case of a 27-year-old woman with an accidental foreign body ingestion, retained intraluminal foreign body contents, and frank esophageal perforation.
Case Description/Methods: The patient in this clinical vignette was attempting to self-induce vomiting with a mechanical pencil when she states that she “accidentally swallowed the pencil”. She developed subsequent hematemesis and dysphagia immediately following this event. Upon presentation to the emergency room, a Chest computed tomography was obtained and revealed pneumomediastinum in the setting of suspected esophageal perforation with pieces of the writing utensil felt to be retained in the proximal esophagus. Given the clinical stability of the patient and these imaging findings, the luminal gastroenterology service was consulted for endoscopic management of esophageal perforation with retained intraluminal foreign object. After a multidisciplinary discussion with radiology and thoracic surgery, endoscopic intervention was planned with the intention to remove the foreign body and place an esophageal stent to manage the perforation. However, upper endoscopy did not reveal a foreign body and was only notable for erythematous posterior oropharynx and an extrinsic, longitudinal bulge in the proximal esophagus suggesting the pencil was extraluminal. An exploratory thoracotomy was subsequently performed. Intraoperatively, a large amount of purulent fluid was noted posterior to the esophagus at the level of the azygous. After the esophagus was identified and isolated, it was felt that the foreign body was retained within the wall of the esophagus (not intraluminal as was previously suspected based on imaging). Through the use of sharp dissection, the tip was identified and the mechanical pencil was removed intact from within the wall of the esophagus. The esophageal perforation was repaired and patient returned to the surgical intensive care unit following completion of the thoracotomy. Following discharge from the surgical service, she was soon readmitted to the psychiatry service for further management of major depressive disorder along with bulimia nervosa.
Discussion: This case demonstrates that clinical stability along with reassuring cross-sectional imaging is not always sensitive for detecting anatomic foreign body location following an ingestion with perforation. These cases require a thoughtful, multidisciplinary approach to management of foreign body ingestions with evidence of perforation on cross sectional imaging.
Figure: A. CT Chest with Pneumomediastinum B. Upper Endoscopy With Erythematous Posterior Oropharynx and an Extrinsic, Longitudinal Bulge in the Proximal Esophagus C. Intraoperative Photograph During Thoracotomy
Mark Radlinski indicated no relevant financial relationships.
Benjamin Robey indicated no relevant financial relationships.
Bryan Sauer indicated no relevant financial relationships.
Daniel Strand indicated no relevant financial relationships.
Mark J. Radlinski, MD1, Benjamin Robey, MD2, Bryan Sauer, MD2, Daniel Strand, MD2. P0431 - The Disappearing Pencil: A Foreign Object Perforation into the Posterior Oropharynx, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.