Asian Cardiovasc Thorac Ann 2002;10:87-88
© 2002 Asia Publishing EXchange Pte Ltd
Esophageal Perforation Caused by a Blister-Wrapped Tablet
Narendar Mohan Gupta, MS,
Vikas Gupta, MS,
Rajesh Gupta, MS,
Vuluchala Sudhakar, MS
|
Department of Surgery Postgraduate Institute of Medical Education and Research Chandigarh, Punjab, India
|
|
|
Narendar Mohan Gupta, MS Tel: 91 172 71 5071 Fax: 91 172 74 4401 email: medinst{at}pgi.chd.nic.in Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab 160012, India.
|
 |
ABSTRACT
|
|---|
An 84-year-old man was diagnosed with esophageal perforation following ingestion of a blister-wrapped tablet. His condition improved after 2 weeks of conservative treatment using antibiotics and high-protein enteral nutrition.
|
INTRODUCTION
|
|---|
The esophagus is one of the most common sites for foreign body lodgment and perforation. This could be attributed to the weak peristalsis generated in the esophagus and its relative unadaptability in comparison to other parts of the gastrointestinal tract because of its relatively fixed structure with movements only in the vertical direction.1
We present a case of esophageal perforation caused by a blister-wrapped tablet. According to our literature search (MEDLARS), this is the first case of its kind.
|
CASE REPORT
|
|---|
An elderly obese male (84 years of age), a known diabetic on oral hypoglycemic agents, presented to a local doctor with a history of a sudden, severe sharp pain in the chest radiating to the back two weeks earlier, which had been relieved with analgesics. Two days after this episode, he started having a moderate grade fever with a productive cough. This was followed by gradually progressive dyspnea. On examination, the patient had tachycardia (110 min-1) and tachypnea (28 min-1). Chest radiograph revealed left-sided pleural effusion. An intercostal tube was inserted and about 1.5 L of purulent fluid drained. Parenteral antibiotics (cefotaxime, amikacin, and metronidazole) were started. Hemogram showed leukocytosis (total leukocyte count, 12,900 mm-3). Liver function test revealed hypoproteinemia (serum albumin, 22 g•L-1). Renal function tests were normal. Electro-cardiography showed evidence of old inferior wall myocardial infarction. Culture of the drained fluid grew mixed bacterial flora, while blood culture was sterile. After 24 hours, the chest tube started draining food particles. The treating physician suspected esophageal perforation and referred the patient to our center.
On reviewing the history, it was discovered that the patient had accidentally ingested a blister-wrapped oral hypo-glycemic tablet (metformin) prior to the onset of pain. Upper gastrointestinal endoscopy showed an esophageal perforation at 31 cm from the incisors. Part of the blister-wrapped tablet was visible through the perforation and was retrieved endoscopically. Study using a water-soluble contrast material revealed a leak from the esophagus with a left-sided esophagopleural fistula (Figure 1
). The rest of the esophagus was normal. Ultrasound of the abdomen showed no evidence of any collection.
View larger version (102K):
[in this window]
[in a new window]
|
Figure 1. Gastrografin study showing extravasation of contrast material from the esophagus into the pleural cavity. A Ryle's tube is in situ.
|
|
The patient was managed by broad-spectrum antibiotics and high-protein enteral nutrition, which was administered through a nasojejunal tube. A prokinetic agent (meto-clopramide) was added to aid gastric emptying and to prevent gastric reflux. The patient's diabetes was controlled by 20 units of plain insulin.
After 2 weeks of conservative treatment, the patient improved nutritionally (serum albumin, 35 g•L-1); leuko-cytosis subsided; and fistula output decreased from 150 mL to 40–50 mL per day. Repeat contrast study showed healing of the perforation, as evidenced by de-creased extravasation of contrast material from the esophagus. However, on day 16 of admission, he developed severe chest pain and breathlessness. Electrocardiography showed changes suggestive of acute myocardial infarction. Subsequently, the patient developed ventricular fibrillation and hypotension, and died.
|
DISCUSSION
|
|---|
Accidental or purposeful ingestion of foreign bodies is common. It is most frequently encountered at the extremes of age and among individuals who are mentally or visually impaired.2 Although the esophagus is the most common site for foreign body lodgment, only 1% leads to perforations.2 The common sites of perforation are cervical esophagus and an area proximal to the narrowed segment.1,2
The chances of foreign bodies lodging in the esophagus are high, and sharp-edged foreign bodies can either directly perforate the organ or get impacted. Once impacted, tissue edema as a result of local trauma tends to grip the foreign body, making subsequent instrumentation difficult. The foreign body will gradually erode and weaken the esophageal wall, which eventually will give way.1,2
Following esophageal perforation, patients usually present with sudden onset of pain and discomfort in the chest.1 These patients later will develop hydropneumothorax, as was observed in the present case. The diagnosis is frequently delayed when the foreign body is radiolucent and the history of ingestion is not forthcoming. The first clue to the diagnosis can be the presence of food particles in the intercostal tube. A high index of suspicion, gastrografin study, and endoscopy can clinch the diagnosis.1,3
Controlled esophageal perforation in an otherwise normal esophagus and without any distal obstruction is managed conservatively in our unit.4 The management protocol includes no oral ingestion, maintaining external drainage of fistula, appropriate antibiotic administration, and early institution of nutrition either parenterally or enterally through a nasojejunal tube.4 On this management, the present patient had started recovery, but unfortunately died of an unrelated cause.
As esophageal perforation is a potentially lethal com-plication, it is recommended that drugs dispensed in blister packs should have instructions on wrapper removal in bold and capital letters.
|
REFERENCES
|
|---|
-
Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg
1978;65:5–9.[Medline]
-
Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc
1995; 41:39–51.[Medline]
-
Backer CL, LoCicero J III, Hartz RS, Donaldson JS, Shields T. Computed tomography in patients with esophageal perforation. Chest
1990;98:1078–80.[Abstract/Free Full Text]
-
Gupta NM. Oesophageal perforation and disruptions. In: Chattopadhyay TK, editor. GI surgery annual. Vol. 6. New Delhi: Saurabh Print-O-Pack, 1999:1–13.
TOP
ABSTRACT
INTRODUCTION
