Recurrent Epigastric Pain in an 82-Year-Old Woman

An 82-year-old woman who had recentlyarrived from Japan presented to theemergency department with a 3-dayhistory of abdominal pain that beganimmediately after she swallowed severalpills with a small amount of water.The severe, intermittent pain radiatedto the patient's back and worsened withmeals. The patient denied chills, nausea,vomiting, coughing, diarrhea, andconstipation. She had well-controlledtype 2 diabetes mellitus and hypercholesterolemia,and had undergone anappendectomy 50 years earlier.

The patient was in moderate distress.Her temperature was 38.3C(101F); blood pressure, 116/44 mmHg; pulse rate, 88 beats per minute;and respiration rate, 19 breaths perminute. Epigastric and right upperquadrant tenderness with no reboundor guarding was noted; Murphy's signwas negative. The white blood cell(WBC) count was 18,500/μL, with7% bands and 89% neutrophils. Liverfunction test results and amylase andlipase levels were normal; there wasno occult blood in the stool.

An ECG showed normal sinusrhythm with no ischemic change; cardiacenzyme levels were normal. Anabdominal ultrasound scan and a hepatic2,6-dimethyliminodiacetic acidscan were negative for gallbladder disease.Chest and abdominal films wereunremarkable.

The pain initially resolved afterthe patient received a GI cocktail(Donnatal, Mylanta, and Xylocaine);she was given a proton pump inhibitorand admitted to the hospital. On thesecond hospital day, the pain returnedand atrial fibrillation was noted; abdominalfindings remained unchanged.The patient was afebrile; her WBCcount was normal. A CT scan of theabdomen revealed small bilateralpleural effusions but no abdominalpathology. The atrial fibrillation resolvedspontaneously.

Figure 1

Figure 2

Two days later, the patient againcomplained of epigastric pain and experiencedatrial fibrillation. Becauseof her recent airplane trip, a spiralCT scan of the thorax was obtained toassess for pulmonary embolism. Thestudy demonstrated mediastinal airposterior to the esophagus (Figure 1)and a possible distal esophageal perforation,which was confirmed by ameglumine diatrizoate esophagramthat revealed extravasation of the contrastconfined to the mediastinum(Figure 2).

Broad-spectrum intravenous antibioticswere initiated. Total parenteralnutrition and intravenous hydrationwere started; nothing was given bymouth.

On hospital day 17, a follow-upesophagram showed that the esophagealperforation had resolved and a roundfilling defect in the distal esophagus persisted,which suggested the presence ofa foreign body (Figure 3). An esophagogastroduodenoscopyrevealed a pillwithin a plastic casing lodged in theesophageal mucosa at the site of theperforation (Figure 4). The dime-sizewrapped pill was removed endoscopicallywithout complications. The patientwas able to tolerate a clear dietand was discharged from the hospital 2days later.

Figure 3

Figure 4

CAUSES OF ESOPHAGEALPERFORATION
Instrumental injury accounts for33% to 48% of all esophageal perforations^1,2;trauma or forceful vomiting(Boerhaave syndrome, see CONSULTANT,May 2001, page 831) and diseasesof the esophagus also cancause perforation.

Esophageal perforation followingforeign body ingestion is rare³; children,elderly persons with dentures,prisoners, and psychiatric patients areat greatest risk. Sharp- or roughedgedobjects, such as bones, coins,needles, toys, and batteries, canpierce and perforate the esophagusspontaneously or during their removalby endoscopy.^4,5 Impacted foreignobjects also can cause slow pressurenecrosis, weaken the mucosa,and lead to perforation.

Pill-induced esophageal injuryresulting in perforation has been reported.^6,7 For our patient, 2 possiblemodes of injury are likely: the sharpobject perforated the distal esophagus,or the sharp foreign body partiallypenetrated the mucosa and induceda pressure necrosis that led toperforation. A similar case of a pill becominga foreign body has been reported,⁸ but we found no instances inthe literature of such an impactioncausing esophageal perforation.

PRESENTATION
The presenting symptoms ofesophageal perforations may differaccording to the perforation's location(cervical, thoracic, or abdominal).The classic triad-pain, fever, and theastinal air-is associated with perforationat all 3 sites.⁵ Patients with cervicalperforation commonly have subcutaneousemphysema and chestpain⁹; those with thoracic perforation,such as this patient, often complain ofupper back and abdominal pain.¹⁰Laboratory investigations may revealleukocytosis.¹¹ Odynophagia and dysphagiaare frequent complaints whena foreign object is present in theesophagus.

DIAGNOSIS
The history is the most importantcomponent in the evaluation of a suspectedesophageal foreign body. Hadthis patient initially reported that shehad swallowed several pills, a delay indiagnosis may have been avoided.

When symptoms develop immediatelyafter instrumentation, thediagnosis of esophageal perforationis obvious. However, in cases ofnoniatrogenic perforation, diagnosisis more difficult. Plain chest filmsand upright abdominal films arevaluable and suggest perforation in90% of patients.¹² Findings can includepneumomediastinum, subcutaneousemphysema, mediastinalwidening, mediastinal air-fluid levels,pleural effusion, pneumothorax,and hydrothorax.

In the remaining 10% of patientswith suspected esophageal perforationswho have unremarkable plainfilms, an esophagram is useful.⁴ Wood;plastic; and thin metals, such as aluminum,are not radiopaque. This patient'schest film was normal, but theesophagram demonstrated a persistentround filling defect that suggesteda foreign body.

Meglumine diatrizoate is thecontrast agent of choice because it iswater-soluble and readily resorbedfrom the mediastinum or pleuralspace. Note that extravasation ofwater-soluble contrast media is notseen in 50% of cervical perforationsand in 20% to 25% of thoracic perforations.⁹ When these studies are negativeand a high level of suspicion persists,consider dilute barium, whichis more sensitive in detecting smallerleaks. If contrast radiography failsto confirm the diagnosis, a CT scanmay be helpful.

MANAGEMENT
Optimal management foresophageal perforation remains controversial.Generally, the patient's underlyingesophageal pathology, thehemodynamic consequences of theperforation, and the extent of theperforation influence the decision toperform surgery.⁵

Surgery. Absolute indicationsfor operative intervention includepneumothorax, pneumoperitoneum,mediastinal emphysema, systemicsepsis, shock, and respiratory failure.¹⁰ Drainage alone, drainage andprimary repair, and drainage andesophageal diversion or esophagectomyare the surgical techniquesused. Aggressive surgical interventionmay reduce mortality but can beassociated with significant morbidity,including strictures and recurrentleaks with prolonged hospitalizationand multiple operations.¹³

Medical therapy. Criteria fornonoperative management of esophagealperforation are:

• A clinically stable patient.

• An instrumental perforation that isdetected before major mediastinal contamination has occurred or a perforationwhose diagnosis has been solong delayed that the patient is able totolerate the injury, obviating the needfor surgery.

• An esophageal disruption that iswell contained within the mediastinumor a pleural loculus.^11,14

Treatment includes broad-spectrumintravenous antibiotics, intravenoushydration, nothing by mouth,nasogastric suction, and total parenteralnutrition.¹⁵ A surgeon needsto monitor the patient as well. Antibioticsare continued until extramuraltears are no longer evident, which istypically 14 days.⁵

First performed 55 years ago,¹⁶immediate surgical intervention hasbeen the mainstay of treatment; however,the recent introduction of moreeffective antibiotics, improved parenteralalimentation and nonoperativemethods of irrigation and drainage,and the emphasis on early diagnosishave led to a cautious trend towardnonoperative treatment.11 Mortalityamong patients who received nonsurgicaltreatment is between 0% and10%.^11,15,17

Studies conducted between the1950s and the 1990s indicated anoverall mortality of between 9% and39% among patients with nonmalignantesophageal perforation.¹⁸ Commoncauses of death include sepsisand multiorgan failure.¹⁹ However, regardlessof the type of therapy chosen,it has been repeatedly shownthat delays in diagnosis and treatmentare associated with increased morbidityand mortality.⁵

This patient's pathology was containedin the mediastinum. She wasclinically stable and, therefore, a goodcandidate for nonoperative therapy.Despite the delay in diagnosis, closeevaluation and standard conservativetreatment resolved the perforation,and the foreign body was removedsuccessfully.

References:

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