Eur J Cardiothorac Surg 2007;31:946-948. doi:10.1016/j.ejcts.2007.01.073
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Aortoesophageal perforation following ingestion of razorblades with massive haemothorax
Ian Hunta,*,
Sarah Hartleyb,
Yasir Alwahabb,
Guy J. Birkillc
a Department of Cardiothoracic Surgery, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK
b Department of Cardiothoracic Surgery, Royal Sussex County Hospital, Brighton, UK
c Department of Radiology, Royal Sussex County Hospital, Brighton, UK
Received 31 October 2006;
received in revised form 24 January 2007;
accepted 29 January 2007.
* Corresponding author. Tel.: +44 208 727200; fax: +44 208 7250211. (Email: ianjhunt{at}gmail.com).
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Abstract
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Aortoesophageal fistula is a rare complication of foreign body ingestion. Typically having ingested a fish or chicken bone, the patient complains of chest pain or discomfort and/or may present with massive gastrointestinal bleeding, which in all but rare cases is fatal. The pathological mechanism may involve perforation and direct communication of oesophagus and aorta usually at the level of the aortic arch; or more usually following oesophageal perforation, the subsequent mediastinal abscess leads to necrosis of the aortic wall. Torrential haemothorax as a result of such a process has not been previously described, though it has undoubtedly occurred. We present a case of massive haemothorax following deliberate ingestion of razorblades that highlights clinically and radiologically the natural course of such a tragic action.
Key Words: Oesophageal perforation • Mediastinitis • Aortoesophageal fistula • Tamponading haemothorax
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1. Introduction
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The first successful surgical outcome following a case of aortoesophageal fistula was reported in 1980 and remains one of only a handful of such published cases [1,2]. Causes described include aortic aneurysms, locally advancing malignancy, foreign body ingestion and trauma including iatrogenic causes [3]. In over 2000 case reviews of foreign body ingestion, only 25 cases (1%) resulted in oesophageal perforation typically involving fish or chicken bones, of which two cases developed an aortoesophageal fistula [4].
Despite the numerous cases published on various aspects of aortoesophageal fistula, most report torrential gastrointestinal haemorrhage and haematemesis as the terminal event [5]. One case reported cardiac tamponade [6]. No doubt, massive haemothorax has occurred as a result of aortoesophageal fistula, but no case describing such an event was identified.
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2. Case report
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A 44-year old Caucasian female with an extensive psychiatric history and previous deliberate self-harm presented to Accident and Emergency (A&E), having swallowed four razorblades and one scalpel 8 days previously. The patient was admitted under the surgical team and had one razorblade removed from the oesophagus and one from the stomach via oesogastroscopy. Admitting chest X-ray was normal and the abdominal X-ray revealed two razorblades in the right colon (Fig. 1
). These moved to the left colon during the course of the patient's admission. Following a 3-day period of observation, the patient remained stable, pain-free and generally well, and was discharged with no further surgical intervention planned.
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Fig. 1. Abdominal X-ray at original admission with razorblades seen in the colon; no razorblades were seen on her presenting chest X-ray.
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The patient re-presented to A&E the next day, complaining of sudden onset, severe abdominal pain and two episodes of vomiting dark brown fluid. Further ingestion of foreign bodies was denied. On examination, the abdomen was tender all over, especially in the epigastric area. Blood pressure and heart rate were normal and chest examination was unremarkable. Erect chest X-ray and abdominal X-ray were normal (with no razorblades noted), and blood results revealed a high white cell count of 25.5 x 109/l and haemoglobin of 13.3 g/dl.
Six hours after admission the patient's condition deteriorated with tachycardia and a blood pressure of 90/50 mmHg. An urgent abdominal computerised tomography (CT) scan was requested. During the CT scan the patient arrested. Cardiac output was regained following aggressive fluid resuscitation and increasing doses of adrenalin. Considering her recent history and despite no overt evidence of gastrointestinal haemorrhage, she was prepared for emergency laparotomy whilst the CT scan was reviewed (Fig. 2 a and b).
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Fig. 2. (a) CT through lower thorax at the time of her arrest demonstrating extravasating intravenous contrast (white arrow) from the aorta. The contrast passes through the gas-containing abscess (arrowhead). Contrast pools in the right pleural effusion (black arrow). Her admitting chest X-ray 1 h previously had been normal. (b) CT at the level of the kidneys at the time of her arrest demonstrating contrast in the aorta (arrow), which is significantly reduced in size due to low blood volume.
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On receiving the CT report in theatre prior to opening the abdomen a right intercostal drain was inserted with the immediate release of over 2 l of ‘fresh’ blood and loss of cardiac output. The cardiothoracic team immediately attended and performed a right posterolateral thoracotomy to relief the tamponading haemothorax. Despite vigorous resuscitation with fluids, blood and adrenalin, the heart was empty and contracting asynchronously. The thoracic aorta was flaccid and a soft tissue collection was noted in the mid-distal oesophagus that was clearly fistulating through to the mediastinum. Subsequent post-mortem confirmed a mediastinal abscess and aortoesophageal fistula but no significant clot in the gastrointestinal tract. No foreign bodies were found.
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3. Conclusion
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The underlying mechanism of aortoesophageal fistula formation is likely to reflect the underlying cause, but typically as in this case, when this is a time lapse between initial insult and subsequent outcome, a process of mediastinal infection or abscess formation and eventual aortic wall erosion is likely to be the cause. Presentation is, therefore, often insidious with what has been described as ‘Chiari's triad’ of central chest pain, sentinel haemorrhage, then a symptom-free interval followed by fatal exsanguinations (named after Hans Chiari, from a case described in 1914 [7]). Exsanguinations are gastrointestinal, typically with massive haematemesis, but in this case no significant blood was noted in the gastrointestinal tract, and massive haemothorax was the fatal event. One can only speculate as to why this was, and may reflect the nature of the objects swallowed, though no razorblades were found in the mediastinum.
Though the outcome may be unavoidable, a high index of suspicion must be present in any patient who accidentally or deliberately ingests foreign bodies, particularly an object such as a razorblade.
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References
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- Ctercteko G, Mok CK. Aorto-esophageal fistula induced by a foreign body: the first recorded survival. J Thorac Cardiovasc Surg 1980;80:233-235.[Abstract]
- Sica GS, Djapardy V, Westaby S, Maynard ND. Diagnosis and management of aortoesophageal fistula caused by a foreign body. Ann Thorac Surg 2004;77:2217-2218.[Abstract/Free Full Text]
- D’Costa H, Bailey F, McGavigan B, George G, Todd B. Perforation of the oesophagus and aorta after eating fish: an unusual cause of chest pain. Emerg Med J 2003;20:385-386.[Abstract/Free Full Text]
- Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg 1978;65:5-9.[Medline]
- Sloop RD, Thompson JC. Aorto-esophageal fistula: report of a case and review of the literature. Gastroenterology 1967;53:768-777.[Medline]
- Sharland MG, McCaughan BC. Perforation of the esophagus by a fish bone leading to cardiac tamponade. Ann Thorac Surg 1993;56:969-971.[Abstract]
- Chiari H. Uber fremdkorperverletzung des oesophagus mitaortenperforation (in German). Berl Klin Wschr 1914;51:7-9.
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Abstract
1. Introduction
