We report an unusual case of dysphagia of a 65-year-old patient caused by the perforation
of the proximal esophagus by an accidentally swallowed toothpick.
The patient presented at our emergency unit with increased dysphagia and retrosternal
pain for the past 6 days. The consumption of solid food had not been possible for
the past 3 days. Swallowing liquids induced retrosternal pain. Choking on a solid
piece of food or accidentally swallowing a foreign body was denied. The symptoms had
started shortly after his last solid meal 6 days previously. The laboratory results
showed elevated C-reactive protein levels (11.6 mg/dl) and an elevated lactate dehydrogenase
of 348 U/l. The patient reported no medical history and no current medication. A computed
tomography scan showed multiple enlarged lymph nodes near the maxilla and a solid
tissue formation in the posterior mediastinum. Below this tumor, a local thickness
of the esophagus was noticed accompanied by pathologic contrast medium-enhancement
of the wall. Moreover, multiple enlarged lymph nodes peritracheal were detected ([Fig. 1]). The patient was suspected of having of an esophageal tumor and was referred to
our unit for upper gastrointestinal endoscopy. The endoscopy showed, at 20 cm below
the alignment, the orifice of a fistula surrounded by fibrin-covered tissue and inflammation
up to 17 cm ([Fig. 2 a]). No signs of a tracheo-esophageal fistula were seen. For further histological examination,
a biopsy from the region of the fistula orifice was taken, during which a toothpick
was discovered and endoscopically removed ([Fig. 2 b]).
Under parenteral nutrition and antibiotic therapy for several days the patient improved
rapidly, and a control computed tomography scan and upper gastrointestinal endoscopy
showed only small areas of residual inflammation.
There are several case reports in the literature reporting ingestion of a toothpick
as the cause for perforation of the stomach, duodenum or even the colon [1]
[2]
[3], but so far no reports describing an esophageal perforation have been published.
Fig. 1 Oblique coronal multiplanar reconstruction (MPR) image from 64-slice multidetector
computed tomography (MDCT) scan of a patient with esophageal perforation. The true
lumen of the esophagus (asterisk), extraluminal free air (arrow), and inflammatory
changes in the mediastinum (arrowhead) are identified.
Fig. 2 Endoscopic view of the fistula orifice 20 cm below the alignment. b The toothpick after taking a biopsy of the lesion and removal of the forceps.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH
