Why We Should Never ‘Wait and See’ with Acute Dysphagia
A previously healthy 36-year-old woman presented at a first aid department with a sore throat and acute dysphagia after ingestion of pasta with dried fish.
A general practitioner inspected the oral cavity, and seeing no abnormalities, sent her home. Five days later, she returned with ongoing and progressive dysphagia, retrosternal pain, and odynophagia. No abnormalities were found in the oral cavity, hypopharynx, or larynx.
Physical examination revealed no fever or other abnormalities. Diagnostic esophagogastroduodenoscopy was performed and showed an impacted structure in the distal esophagus (Figure A). The patient’s chest was evaluated by computed tomography, and the image (Figure B) revealed a radiopaque structure in a thickened esophageal wall and a pleural fluid collection.
Based on these images, the patient was found to have bilateral perforation of the esophagus from a fish vertebra.
The tip of a fish bone’s costa perforated the wall and was only 2 mm from the left atrium. The other costa had perforated the right pleural cavity, and there was a small amount of fluid collection. No pneumomediastinum was seen.
van der Vlugt et al. were concerned because perforation of the esophagus is one of the most serious complications of the digestive tract.
The authors removed the bone via endoscopy, with the cardiac surgical team on standby because of the bone’s close relation to the left atrium. The structure was rigid; its removal required cutting with an endoscopic scissor until 1 of the costovertebral joints became flexible. Then, the other costa could be flexed into the lumen while the vertebral body was pushed distally.
The structure was extracted and found to be 3.3 cm long. After the bone was removed, 2 small bilateral ulcers were observed, with no clear defects. The patient was given broad-spectrum antibiotics and placed on gastrointestinal rest. A contrast radiograph taken 1 day later showed no leakage. The patient was discharged 1 week later in good clinical condition.
van der Vlugt et al. conclude that acute dysphagia should never be approached with a wait-and-see policy. However, they state that bilateral esophagus perforation can be treated conservatively.