Asian Cardiovasc Thorac Ann 2002;10:280-281
© 2002 Asia Publishing EXchange Pte Ltd
Retroesophageal Hematoma Caused by Fish Bone Perforation of the Esophagus
Jacques Jougon, MD,
Antonio Minniti, MD,
Patrick Moralès, MD1,
François Laurent, MD1,
Jean François Velly, Md
Department of Thoracic Surgery
1 Unit of Thoracic and Cardiovascular Radiology Haut-Lévêque Hospital Bordeaux University Hospital Pessac, France
|
|
|
For reprint information contact: Jacques Jougon, MD Tel: 33 55 765 6009 Fax: 33 55 765 6021 email: jacques.jougon{at}chu-bordeaux.fr Department of Thoracic Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Avenue de Magellan, Pessac Cédex 33604, France.
|
 |
ABSTRACT
|
|---|
A 39-year-old man complained of acute dysphagia and dorsal pain while eating fish. Radiologic and endoscopic studies revealed a retroesophageal mass, which was later shown to be a hematoma.
|
INRODUCTION
|
|---|
Mediastinitis is the most frequent consequence of foreign body perforation of the esophagus.1 An arterioesophageal fistula is another, though rare, complication induced by foreign bodies. We report a rare case of retroesophageal hematoma produced by a fish bone.
|
CASE REPORT
|
|---|
A 39-year-old man was referred for suspected mediastinal tumor. He complained of an acute pain in his neck and back while eating fish 2 days earlier. Mild dysphagia followed, but he was able to finish eating. The following morning, however, he was unable to eat. The pain also worsened.
The patient had no medical history except for smoking. His temperature was 37.5°C, pulse rate 70 beatsámin-1, respiratory rate 20 min-1, and blood pressure was 130/80 mm Hg. Physical examination, white blood cell count, and coagulation test were normal. The chest radiograph showed mediastinal enlargement (Figure 1
). Computed tomography revealed a spontaneously hyperattenuated large posterior mass (Figure 2), which indicated recent bleeding. The esophagogram showed narrowing of the esophageal lumen from compression without leakage. A retroesophageal hematoma was suspected. Rigid esophagoscopy disclosed a fish bone protruding from the posterior wall of the esophagus, 22 cm from the incisors. The bone was readily extracted by forceps, and a nasogastric tube was installed for decompression. A cervical incision along the anterior edge of the sternocleidomastoid muscle was made to explore the cervical esophagus. A large filled hematoma was found between the posterior esophageal wall and the deep cervical fascia, extending down to the aortic arch. There was no pus or necrotic material. The hematoma was aspirated and the mediastinum debrided and cleaned. No esophageal tear was found, and there was no bleeding in the operative field. The mediastinum was drained. Broad-spectrum antibiotic therapy was given.
View larger version (98K):
[in this window]
[in a new window]
|
Figure 2. Computed tomographic scan after intravenous contrast injection showing a large heterogeneous mass behind the trachea. The peripheral part of the mass was spontaneously hyperattenuated, but no enhancement was seen after contrast injection.
|
|
The postoperative course was uneventful. A water-soluble contrast study performed on postoperative day 7 was normal, and the patient was allowed to resume oral feeding. He was discharged on postoperative day 10. At follow-up 2 months following operation, he had no complaints and the barium esophagogram was normal.
|
DISCUSSION
|
|---|
Sudden pain and dysphagia during eating, and associated with mediastinal shadow, are most commonly due to esophageal perforation. In our case, mediastinitis associated with the esophageal perforation was unlikely because of the absence of sepsis and the rapid appearance of a large mediastinal shadow without pleural effusion. Iatrogenic or posttraumatic retropharyngeal hematoma has been reported,2 but to our knowledge this was the first case of retroesophageal hematoma produced by a foreign body. Two other similar but rare esophageal lesions are intramural hematoma of the esophagus3 and arterioesophageal fistula caused by a foreign body.4–7 The former may be spontaneous and is usually associated with clotting disorders. It has also been described after endoscopic variceal sclerotherapy and may be a com-plication of tracheal intubation. The latter may present as an aortoesophageal or subclavian arterioesophageal fistula. The site of the vessel tear has been reported on the aortic wall, 1 to 5 cm from the origin of or on the left subclavian artery,6 or on a right retroesophageal subclavian artery.4 Bleeding may appear a few days after removal of the foreign body, accompanied by hematemesis.5 Esophageal insertion of a Sengstaken-Blakemore tube stops the bleeding and allows emergency surgery.4
In our patient, the site of the perforation was opposite to large mediastinal vessels, and he did not have any retroesophageal subclavian artery or clotting disorder. There was no blood in the esophageal wall or bleeding in the operative field. It was likely that the bleeding came from small vessels in the mediastinum, such as an intercostal artery. Whatever the origin of the bleeding, the risk of a delayed life-threatening arterioesophageal fistula requires the patient to be followed in a specialized thoracic unit. Surgical treatment was advisable mainly because of the risk of developing descending mediastinal abscess. Furthermore, without surgical drainage, evacuation of such a large hematoma may not be complete, which may develop into a calcified compressive retroesophageal mass in the long term.
|
REFERENCES
|
|---|
- Nashef SA, Klein C, Martigne C, Velly JF, Couraud L. Foreign body perforation of the normal oesophagus. Eur J Cardio-thorac Surg
1992;6:565–7.[Abstract]
- Senthuran S, Lim S, Gunning KE. Life-threatening airway obstruction caused by a retropharyngeal haematoma. Anaesthesia
1999;54:674–8.[Medline]
- Phan GQ, Heitmiller RF. Intramural esophageal dissection. Ann Thorac Surg
1997;63:1785–6.[Abstract/Free Full Text]
- Wu MH, Lai WW. Aortoesophageal fistula induced by foreign bodies. Ann Thorac Surg
1992;54:155–6.[Abstract]
- Mok CK, Chiu CS, Cheung HH. Left subclavian arterioesophageal fistula induced by a foreign body. Ann Thorac Surg
1989;47:458–60.[Abstract]
- Leow CK. Subclavian arterio-esophageal fistula secondary to fish bone impaction: report of a case. Surg Today
1998;28:409–11.[Medline]
- Heckstall RL, Hollander JE. Aortoesophageal fistula: recognition and diagnosis in the emergency department. Ann Emerg Med
1998;32:502–5.[Medline]
TOP
ABSTRACT
INRODUCTION
