Although the ingestion of foreign bodies is not uncommon, it rarely causes severe complications. The perforation rate reported in the literature varies depending on the size and type of foreign bodies, ranging from 0% to 4%, but it represents a life-threatening emergency, and delay in diagnosis can result in a significant increase in morbidity and mortality (McMahon, O'Kelly, Lim, Ravi, & Reynolds, 2009). Occasionally, it may lead to penetration injuries resulting in severe complications such as cardiac tamponade, aortic pseudoaneurysm, and mediastinitis. Penetration injuries are associated with a high mortality rate of 20% (Tan, Tan, Peng, & Yu, 2015). In this case, the swallowed foreign body, a steel wire, caused the cardiac tamponade after penetrating the esophagus into the pericardium.
Case Report
A previously healthy 48-year-old man swallowed a sharp object accidently while eating fish. He thought that it might be a fish bone and then he tried to take solid food in an attempt to ingest it. However, it was not successful. One day later, he presented to our hospital with a history of slowly increasing retrosternal pain.
Physical examination was unremarkable on his arrival. Computed tomographic (CT) scan of the chest disclosed a radiodense linear foreign body that measured 1.8 cm in length, penetrating the esophagus into the pericardium and a corresponding hemopericardium (Figure 1). The patient's systolic blood pressure rapidly decreased to 79 mmHg 2 hours after his arrival, and an urgent median sternotomy was performed.
During the procedure, the pericardium was found to be very tense, and the hemodynamics immediately improved after it was incised and clots removed. Afterward, cardiopulmonary bypass was performed. A steel wire was found to be perforating the esophagus and the pericardium just at the left side of the posterior descending artery, and there was a clearly identifiable abrasion of the left ventricle, measuring 3 cm in length and 0.5 cm in depth. The steel wire was removed (Figure 2), and the abrasion of the left ventricle and perforation of the pericardium were repaired with 4-0 Prolene sutures. After the intraoperative radiological examination showing nothing was left, the patient was sent to our intensive care unit. Considering the size of the esophageal perforation and the patient's age, he was managed conservatively with no oral intake, suction via a nasogastric tube, and broad-spectrum antibiotics.
The esophageal perforation was resolved on the seventh postoperative day, allowing realimentation. The patient was discharged on the 10th day without any unexpected event. One month later, he was well and on a normal diet and did not have chest pain or any other symptoms.
Discussion
Foreign body ingestion is a common occurrence in clinical practice. Approximately 80%-90% of ingested foreign bodies will pass through the gastrointestinal tract spontaneously without clinical sequelae (Sung et al., 2011). However, the perforation rate could be as high as 15%-35% when sharp foreign objects are ingested (Cho, Lee, Han, & Woo, 2014). Moreover, the attempt to ingest the foreign body with other food is the most common cause of penetration injuries. An urgent surgical procedure is required once the penetration injury occurs. Sternotomy with cardiopulmonary bypass is the gold standard of surgical treatment of cardiovascular injuries, and the intervention is the optimal choice for descending aortic injuries (Chen, Yu, Li, Xiao, & Liu, 2011).
In this case, the patient accidentally swallowed a sharp steel wire while eating fish, and it penetrated the pericardium from the middle esophagus resulting in an abrasion of the left ventricle, leading to cardiac tamponade. During the procedure, the heart needed to be lifted up and repaired. Thus, the cardiopulmonary bypass was necessary. Moreover, the penetration injuries in the aorta and myocardium always require urgent intervention because of pulsation.
Early diagnosis and appropriate treatment are essential for patients with ingested sharp objects. The diagnosis of esophageal perforation depends on a high degree of suspicion, recognition of clinical features, and confirmation by iohexol esophagography or endoscopy. However, CT is recommended to clarify and evaluate the diagnosis and severity of penetration injuries. For these patients with penetration injuries, an urgent surgical procedure will be required to repair penetration injuries and remove foreign bodies. The small esophageal perforations tend to seal without sequelae and can be managed conservatively.
Conclusion
Patients with ingested sharp foreign bodies are at higher risk for severe complications. Urgent surgery is required to treat the hemorrhage caused by penetration injuries. However, it is important to seek medical advice as soon as possible for these patients with ingested foreign bodies.
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