|Year : 2019 | Volume
| Issue : 2 | Page : 79-81
Pseudodiverticulum formation by metallic foreign body in esophagus: A concealed presentation
Anshuman Darbari1, Neeraj Kumar2, Ashikesh Kundal1, Anil Pandey3, Saurabh Varshney3
1 Department of CTVS, AIIMS, Rishikesh, Uttarakhand, India
2 Department of T and EM, AIIMS, Rishikesh, Uttarakhand, India
3 Department of Otorhinolaryngology (ENT), AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||15-Apr-2019|
|Date of Acceptance||29-Sep-2019|
|Date of Web Publication||25-Nov-2019|
Dr. Anshuman Darbari
Department of CTVS, AIIMS, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Foreign body (FB) ingestion is a common problem in children, and coins are the most frequently ingested FB all over the world due to easy availability in household area. In the majority of these cases, coins usually pass through the esophagus without any complication, but rarely impacted coins can cause complications due to pressure necrosis of wall. Hereby, we report a case of pseudodiverticulum formation due to retained metallic FB (coin) and later successful surgical management.
Keywords: Diverticulum, endoscopy, esophagus, foreign body
|How to cite this article:|
Darbari A, Kumar N, Kundal A, Pandey A, Varshney S. Pseudodiverticulum formation by metallic foreign body in esophagus: A concealed presentation. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2019;3:79-81
|How to cite this URL:|
Darbari A, Kumar N, Kundal A, Pandey A, Varshney S. Pseudodiverticulum formation by metallic foreign body in esophagus: A concealed presentation. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2019 Dec 14];3:79-81. Available from: http://www.aiaohns.in/text.asp?2019/3/2/79/271601
| Introduction|| |
Foreign body (FB) ingestion is a common problem in children, and coins are the most frequently ingested FB all over the world due to easy availability in household area. Most of the times, these are asymptomatic without any consequences or may present with subtle symptoms such as drooling, vomiting, dysphagia, pain, or a FB sensation. Because coins lack sharp edges, they usually pass through the esophagus without any complication, but impacted coins can cause complications rarely due to pressure necrosis of wall with possible perforation and fistula formation to adjoining structure. It is very rare for ingested coin to form a pseudodiverticulum and give a concealed confusing presentation. We report a case of pseudodiverticulum formation due to retained metallic FB and successful management.
| Case Report|| |
A 10-year-old boy was admitted to our emergency department with complaints of mild pain during swallowing for 3 months, prior to which the patient was apparently well. Pain was acute in onset, mild in nature, aggravated on eating solids, nonradiating, and not relieved by medications. The patient visited a local practitioner 10 days before coming to our hospital with the same complaint, and X-ray neck with upper chest region was done, which was suggestive of a metallic FB. On review of history, the patient confirmed about accidental swallowing of a metallic coin 3 months back. Detailed history was taken from the patient and later it was also supported by his father.
On physical examination, the patient had fair general condition with stable vitals. There was no breathing difficulty, no change in voice, afebrile, and without cough or chest pain. On local examination of the neck, no obvious swelling was seen or palpated. On pulse oximetry, SpO2 was 98% and nutritional status was satisfactory. Pertinent radiographic findings revealed a circular metallic FB in the upper aerodigestive tract, probably in the esophagus at the level of sternoclavicular junction proximal to tracheal bifurcation. All routine blood investigations were within normal limits.
As a clear, circular metallic coin FB was seen, FB removal attempt was initiated by an otolaryngology specialist under general anesthesia by rigid eosphagoscopy as a standard treatment method. Surprisingly, esophagoscope was negotiated up to esophagogastric junction and the whole lumen was found to be free of any FB. After various attempts, C-Arm radiography help was sought and it showed the presence of metallic FB just underneath esophagoscope [Figure 1]. Further retrieval attempts failed, so the procedure was abandoned. The patient was reinvestigated with barium study [Figure 2], and contrast-enhanced computed tomography (CECT) neck with thorax and FB was reconfirmed at the level of C7 and it was masquerade to be presented just outside lumen of the esophagus forming a diverticular pouch. With backup of thoracic surgical team, again rigid esophagoscopy under general anesthesia was attempted and there was no FB visualized in the anterior part of the esophageal lumen. On meticulous inspection, on the posterior wall of the esophagus, faint impression of the metallic FB (Indian “1” rupee coin) was seen [Video 1]. After dissection over it, it was also found to be herniating extraluminally through a very small pinhole defect with overlying granulation tissue. Extraction of this was attempted via esophagoscope by grasping forceps repeatedly, but failed because of severe impaction and surrounding by excessive granulation tissue [Videos 1 and 2 ]. Open cervical exploration was done in the same sitting by a thoracic surgeon, and after esophagotomy, the metallic coin was removed, which was densely impacted and formed a pseudodiverticulum. After diverticulum resection, the esophageal wall was repaired in standard fashion, and after putting corrugated drain, a Ryle's tube was passed up to the stomach and the wound was closed. Minor leak from the drain site was present on day 6, so gastrografin swallow study on postoperative day 9 was done and it showed focal contrast pooling at C7 level suggestive of minor operative site leak. After conservative management, repeat gastrografin swallow on postoperative day 14 showed no contrast leak along thoracic and abdominal esophagus. Rest, postoperative period remained uneventful. The Ryle's tube was removed on postoperative day 15 and oral feed was gradually started and the patient was discharged on postoperative day 18 under stable and satisfactory conditions. He is on regular follow-up for the last 8 months without any complaint or radiological abnormality.
|Figure 1: Photograph of C-arm radiograph monitor anteroposterior view showing metallic foreign body just overlapping esophagoscope. In inset-lateral view showing metallic foreign body just underneath esophagoscope|
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|Figure 2: Contrast-enhanced radiological study of esophagus showing metallic foreign body in the esophagus with diverticular pouch and intact lumen|
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| Discussion|| |
Worldwide, most commonly ingested FB in the pediatric population is coin. Other foreign bodies those are commonly ingested are food related, such as seeds and nuts, bone, and meat bolus and also pins magnets, and toys. The most common ingested FB in the elderly is dentures. Children within the age group of 6 months to 5 years and risk group in adult population such as prisoner, alcoholics, psychiatric patient, and old age edentulous person are found to be more prone to FB ingestion.
Clinically, esophageal FB ingestion may be asymptomatic, especially in children and may go unnoticed due to the lack of proper history. Usually asymptomatic, but it may present with subtle symptoms such as dysphagia, odynophagia, chest pain, and laryngeal irritation. Emphasis must be given to seek the history as presentation may be varied. Cricopharyngeal ring, aortic arch indentation, and esophagogastric junction are three anatomical narrow areas where lodgment of FB may occur in the esophagus.
For metallic and radiopaque foreign bodies, confirmation of FB is always done by radiological investigation. X-ray neck and chest region with lateral and anteroposterior view is very useful and easy tool for localization of FB. Barium studies should be avoided if there is suspicion of rupture as it can create more complication or confuse endoscopic examination. Endoscopy is the standard modality of choice for the diagnosis and management of FB ingestion as the accuracy is near 100% due to direct visualization.
Usually, most of the foreign bodies, especially coins, pass through the esophagus without any complication and does not require any treatment medically or surgically. However, rarely, it gets impacted. In impacted cases, majority of cases require endoscopic intervention and in only 1% cases surgical intervention is required. Coins should be removed when blocking the esophagus and when size is larger than 25 mm or retained for >3 weeks in the stomach. Although most of the time it can be removed by esophagoscope, surgical exploration may be needed rarely and includes involvement of ENT surgeon, thoracic surgeon, and gastro surgeon.,
Unfortunately, not all impacted esophageal foreign bodies give symptoms in acute period, especially in children. Chronic, asymptomatic, or chance X-ray findings are also common. Prolonged duration of impaction or unwitnessed ingestion of unsuspected foreign bodies are associated with increased risk of esophageal injury and possible rare complications, including bronchoesophageal fistula, aortoesophageal fistula, esophageal perforation, stricture, and like in our case a pseudodiverticulum formation.
Extraction in chronic esophageal foreign bodies is difficult due to excessive granulation tissue and it generally requires rigid endoscopy. In some cases, like in ours, the patient had to undergo surgical exploration for removal.
In our case, X-ray neck and chest was suggestive of metallic coin FB in the esophagus at the level of sternoclavicular junction. Its retrieval by rigid esophagoscope was attempted, but failed as FB could not be visualized and was outside lumen. CECT thorax was done to confirm the location and as there was masquerade presentation. FB may have eroded mucosa and herniated through posterior esophageal wall and contained in pseudodiverticula, so it was not visualized on initial esophagoscopy and later it was found to be densely embedded in the esophageal wall surrounded by chronic granulation tissue and producing initial visual impression. Hence, surgical exploration and retrieval was done with pseudodiverticulum repair.
| Conclusion|| |
Although various types of esophageal foreign bodies and retrieval have been reported, now, an established standard method of removal is by rigid esophagoscopy. However, our patient created a rare case scenario, where within the duration of 3 months, the metallic coin had been herniated through the wall and formed a pseudodiverticulum with severe perioesophagitis, so open surgery has to be performed as definitive management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for the patient's images and other clinical information to be reported in the journal. The patient's parents understand that the patient's name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We are also thankful to other team members Dr. Shashikant, Dr. M. Shoeb from Cardiothoracic Department and Dr. Manu Malhotra from ENT Department for operative support and management of this case.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]