Aortoesophageal fistula: a case report.
Patients with impacted foreign bodies in the upper aerodigestive tract present commonly to ENT clinics. This case report highlights two important issues in the management of these patients. First, if the evidence of esophageal perforation is strong and contrast swallow is negative, the physician must consider further imaging, such as contrast computed tomography. Second, ENT physicians must beware of the complications of esophageal trauma, including major vascular injury and aortoesophageal fistula, in patients with retained sharp foreign bodies in the mid-esophagus.
Aortoesophageal fistula is a catastrophic complication of foreign body ingestion. ENT physicians frequently see patients with impacted foreign bodies in the upper aerodigestive tract. In Birmingham City Hospital, 133 admissions due to esophageal foreign body impaction were recorded between 2000 and 2004. (1) We present a pediatric case of aortoesophageal fistula developing 6 days after removal of a chicken bone via rigid esophagoscopy.
A 14-year-old girl presented to the Accident and Emergency Department with sharp central chest pain. She recalled having eaten chicken the night before without complaint. She was hemodynamically stable, and fiberoptic nasendoscopy was negative. She was admitted directly under the care of Otolaryngology for observation. She developed a temperature of 38.5[degrees]C overnight.
On day 2, the patient was still in pain. She was stable and her temperature was normal. Flexible gastroscopy revealed a chicken bone impacted at 27 cm (figure). The bone was grasped but not dislodged; we then removed it via rigid esophagoscopy. Pus flowed from the left wall of the esophagus, and we noted mild ulceration on the right wall. A postoperative chest x-ray showed no pneumomediastinum.
By day 5, after intravenous antibiotics and analgesia, the patient had been asymptomatic and apyrexial for 24 hours and was discharged. On the evening of day 6, however, she returned to the Accident and Emergency Department with central stabbing chest pain radiating to the back. The pain was of sudden onset and occurred when she was taking tablets. In that department she was observed to have vomited 200 ml of blood. She developed signs consistent with Grade II hypovolemic shock. After resuscitation with crystalloid, her hemoglobin dropped from 14.8 g/dl to 9.8 g/dl.
A repeat chest x-ray was unremarkable, and an urgent contrast swallow with Gastrograffin demonstrated no perforation. The patient decompensated further and required resuscitation with blood products. She was transferred urgently to tertiary level services.
Flexible esophagogastroscopy demonstrated a bleeding point. A Sengstaken-Blakemore tube was inserted. Pressures above the systolic blood pressure were required to gain hemodynamic control. A diagnosis of aortoesophageal fistula was made, and an emergency thoracotomy was performed. Primary repair of the esophagus and aorta was conducted.
Despite our patient's recovery over days, resulting in discharge to the general wards, a rebleed mandated revision surgery and grafting of the aorta.
Impaction of foreign bodies in the upper aerodigestive tract is a common presentation. Coins, fish bones, and toy parts can become impacted in the palatine tonsils, base of the tongue, pyriform fossa, vallecula, or at the classic points of narrowing in the esophagus. In a study of more than 400 patients, the most common sites of foreign body impaction within the esophagus were at the level of the postcricoid region (57%), the aortic arch and left main bronchus (26%), and the distal gastroesophageal junction (17%). (2)
In the same study, aortoesophageal fistula occurred in only 1 patient, who subsequently died. (2) Scher et al cited 86 cases of fatal aortoesophageal fistula. (3) Other complications such as retroesophageal abscess, mediastinitis, and pneumothorax are well recognized. (4) Rarer complications include pericardial injury, resulting in cardiac tamponade. (5) and migration of fish bones to the thyroid and liver in association with upper esophageal and gastric perforations, respectively. (6,7)
Aortoesophageal fistula presents with a Chiari's triad of chest pain, a symptom-free interval, and a transient, self-limiting "herald bleed." (4) When untreated, this series of symptoms precedes a fatal hemorrhage.
When there is a delay between foreign body ingestion and presentation, the aortic perforation may become mycotic. Our patient had an interval of 6 days between presentation and the initial bleed. An average symptom-free interval of 8 days is recorded in the literature. (8)
Identifying the presence and site of the foreign body and conducting early and safe retrieval are key principles of management. Most foreign bodies are satisfactorily retrieved by ENT surgeons with rigid esophagoscopy and grasping forceps. Elegant techniques are described by Chevalier Jackson. (9)
If esophageal perforation is suspected, current practice recommends urgent investigation. The initial definitive test is a contrast swallow. If a perforation is diagnosed, further imaging is required to exclude vascular involvement. In our case, the test yielded a false-negative result. Computed tomography of the chest was reported to identify an aortoesophageal fistula in 2 cases in the literature. 10. (11) This prompted surgery in both cases, with favorable outcomes.
We believe this case highlights two important issues. First, if the evidence for a perforation is strong, the physician should consider further imaging, even if the contrast swallow is negative as it was in the present case. Second, ENT physicians must beware of the complications of major vascular injury in patients with retained sharp foreign bodies in the mid-esophagus.
(1.) Data on diagnosis ICD10 Code T18I, Hospital Episode Statistics: Financial Years 2000-2004. Clinical Audit Department, Sandwell and West Birmingham Hospitals NHS Trust, West Midlands, U.K.
(2.) Athanassiadi K, Gerazounis M, Metaxas E, Kalantzi N. Management of esophageal foreign bodies: A retrospective review of 400 cases. Eur J Cardiothorac Surg 2002;21 (4):653-6.
(3.) Scher RL, Tegtmeyer CJ, McClean we. Vascular injury following foreign body perforation of the esophagus. Review of the literature and report of a case. Ann Otol Rhinnol Layngol 1990;99(9 Pt 1):698-702.
(4.) Bancewicz J, Owen WJ. Chap 21. In: Burnand KG, Young A, Lucas JD, et al, eds. The New Aird's Companion in Surgical Studies. 2nd ed. London: Churchill-Livingstone; 1998:530-1.
(5.) Sharland MG, McCaughan BC. Perforation of the esophagus by a fish bone leading to cardiac tamponade. Ann Thorac Surg 1993; 569(4):69-71.
(6.) Bendet E, Horowitz Z, Heyman Z, et al. Migration of fishbone following penetration of the cervical esophagus presenting as a thyroid mass. Auris Nasus Larynx 1992;19(3):193-7.
(7.) de la Vega M, Rivero JC, Ruiz L, Suarez S. A fish bone in the liver [Letter]. Lancet 2001;358(9286):982.
(8.) Fukunaga T, Yamamoto K, Mizoi Y, et al. Aortoesophageal fistula by swallowed foreign body--a case report and review of the literature. Nihon Hoigaku Zasshi 1989;43(4):337-47.
(9.) Jackson C. Bronchoscopic removal of safety-pins. Arch Otolaryngol 1926;3(5):423-8.
(10.) D'Costa H, Bailey F, McGavigan B, et al. Perforation of the oesophagus and aorta after eating fish: An unusual cause of chest pain. Emerg Med J 2003;20(4):385-6.
(11.) Lim CC, Cheah FK, Tan JC. Spiral computed tomography demonstration of aorto-oesophageal fistula from fish-bone. Clin Radiol 2000;55(12):976-7.
David Tighe, MBChB; Andy Wood, MB; Savita Kale, MRCS(Eng)
From the Department of Otolaryngology, Birmingham City Hospital, Birmingham, U.K.
Corresponding author: Mr. David Tighe, Ear, Nose & Throat Department, Sandwell Hospital, Sandwell and West Birmingham NHS Trust, Lyndon, West Bromwich, West Midlands B71 4HJ, UK. Phone: 44(0) 121-553-1831; fax: 44(0) 121-553-1831; e-mail:firstname.lastname@example.org
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Tighe, David; Wood, Andy; Kale, Savita|
|Publication:||Ear, Nose and Throat Journal|
|Article Type:||Case study|
|Date:||Feb 1, 2009|
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