This report describes perforation of the oesophagus after eating fish complicated by perforation of the aorta six days later. The patient had not knowingly swallowed a fish bone. Aorto-oesophageal fistula is almost universally fatal. In the case described here, the fistula was demonstrated on contrast computed tomography before surgery, thus informing surgical management. The patient is the eighth reported survivor.
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In a series of 2394 cases of retained oesophageal foreign body reported from Hong Kong, perforation occurred in 25 cases (1%) and aorto-oesophageal fistulas in two cases (0.08%).1 A wide variety of objects was retained in the oesophagus but fish bones were the most common (60%) and chicken bones the second most common (16%). Fish and chicken bones seem to be most commonly associated with major complications—particularly in parts of the world where unfilleted fish is eaten—but other foreign bodies, for example coins, have perforated the oesophagus2 and fatal oesophago-aortic perforation by a coin has been described in a child of three.3 The diagnosis is frequently missed at initial presentation, as in the case reported here.
A 57 year old woman attended the emergency department with a two hour history of dull central chest pain that radiated into her back. It had begun while eating fish (sea bass), although she had not knowingly swallowed a fish bone. There were no other symptoms and she was normally in good health. Examination and investigations (chest radiography, ECG, full blood count, and biochemistry screen) were thought to be normal. Her pain subsided apart from some discomfort on swallowing and she was discharged home. She reattended the department six days later. She complained that she had been cycling up a hill and had developed severe chest pain radiating into her jaw together with some sweating. Moreover, the discomfort of which she had previously complained had persisted. On examination she had a pulse of 92 per minute, BP 142/72 mm Hg, Sao2 98% on air and temperature 36.5°C. There were no cardiovascular, respiratory, or abdominal signs. There was no surgical emphysema in the supraclavicular fossae. The investigations were repeated and she now had a raised white cell count (16.3×109/l with a neutrophilia), a somewhat lower haemoglobin concentration (12.7 g/dl previously 14.4 g/dl) and an increased C reactive protein concentration (46 mg/l previously <8 mg/l). The ECG was normal. Review of her first chest radiograph showed a probable pneumomediastinum. An oesophageal perforation and mediastinitis were diagnosed. Accordingly, she was given analgesia and high dose intravenous antibiotics. She was admitted but had a respiratory arrest a few hours later necessitating intubation and ventilation. There was extreme difficulty in inserting the endotracheal tube; subsequent computed tomography showed a large posterior mediastinal abscess displacing and compressing the proximal trachea. A dynamic, enhanced scan (100 ml Omnipaque 300 intravenous) demonstrated pooling of contrast within the abscess cavity, closely adjacent to the aortic arch (fig 1). It was assumed that there was an aortic fistula. She was transferred to a regional centre with cardiopulmonary bypass available. She survived; the successful surgical management of her aorto-oesophageal fistula will be the subject of a separate publication (N Maynard, personal communication).
Perforation of the oesophagus and aorta by foreign bodies has been reported surprisingly often and is almost universally fatal. For example, fatal perforation of the oesophagus and aorta by a fish bone was described by Scher et al4 and these authors cited a further 86 cases of fatal aorto-oesophageal fistula. Fish bone ingestion has caused a subclavian-oesophageal fistula5 and has also caused perforation of the pericardium with cardiac tamponade.6 There is a tendency for fish bones to migrate and one has been found in the thyroid after perforation of the cervical oesophagus,7 and others in the liver after gastric or gastrointestinal perforation.8,9 Foreign bodies most commonly perforate the cervical oesophagus.1 The second most common site for perforation is at the level of the aortic arch1 where there is scope for fatal or life threatening vascular and respiratory catastrophe—as in the case of a 38 year old man who unknowingly swallowed part of a cocktail stick, which perforated his oesophagus and aorta and caused a catastrophic haematemesis 10 days later.10 When there is a delay between ingestion and presentation the aortic perforation may be mycotic (that is, it follows damage to the aortic wall caused by adjacent sepsis), as is probable in the case reported here. The first survivor of oesophago-aortic perforation was described in 1978 after cross clamping the aorta11 and currently there are only six other survivors listed on Medline. Our own case illustrates the typically subtle initial presentation of this potentially fatal condition. Characteristically, a fatal, exsanguinating haematemesis is preceded by a minor sentinel bleed a few days earlier and mild oesophageal pain (chest pain possibly radiating to the back or root of the neck, and worse on swallowing).4,11 Therefore any patient with a presentation that is suggestive of a perforating oesophageal foreign body should be investigated urgently. Once a perforation has been confirmed, a dynamic contrast computed tomogram or arch aortogram is essential to exclude vascular involvement. Any patient with an aortic fistula should be referred to a centre where cardiopulmonary bypass is available.
The authors would like to thank Carol Mortimer, hospital librarian, for searching Medline and obtaining papers.
All authors had clinical responsibility for the patient and contributed to the content of the paper. The manuscript was written by Horace D’Costa, Grizelda George, and Bryan Todd.
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