Aortic Pseudoaneurysm Secondary to Mediastinitis due to Esophageal Perforation

Esophageal perforation is a condition associated with high morbidity and mortality rates; it requires early diagnosis and treatment. The most common complication of esophageal rupture is mediastinitis. There are several case reports in the literature of mediastinitis secondary to esophageal perforation and development of aortic pseudoaneurysm as a complication. We report the case of a patient with an 8-day history of esophageal perforation due to foreign body (fishbone) with mediastinitis and aortic pseudoaneurysm. The diagnosis was made using Computed Tomography (CT) with intravenous and oral water-soluble contrast material. An esophagogastroduodenoscopy did not detect the perforation

Primary aortoesophageal fistula from metallic bristle ingestion

Although many patients are treated for the removal of ingested foreign objects each year, ingestions that perforate the esophagus and lead to intra-abdominal complications are rare. Aortoesophageal fistulas and aortic pseudoaneurysms are deadly complications of esophageal foreign body impaction. However, the surgical approach to aortic repair from foreign object damage has not been standardized. We have described the diagnostic, open surgical, and therapeutic approach to treating a man who had accidentally ingested a 3-cm metallic bristle that lodged in his aortic wall. The patient recovered after excision of the aortic pseudoaneurysm with CryoGraft (CryoLife, Inc, Kennesaw, Ga) replacement, drainage of abscesses, and antibiotic treatment for multiple infections

An interesting journey of an ingested needle: a case report and review of the literature on extra-abdominal migration of ingested Foreign bodies

Swallowed foreign bodies encounter a major problem especially in children, but fortunately they mostly do not cause any related complication and are easily passed with the stool. In this paper, an interesting journey of a needle is presented. A 20-year old female admitted to our emergency service after she had swallowed a sewing machine needle, which is initially observed in the stomach in the plain abdominal radiography. During the follow-up period, the needle traveled through bowels, and surprisingly was observed in the left lung on 10th day of the follow-up. It was removed with a thoracotomy and pneumotomy under the fluoroscopic guidance. The postoperative period was uneventful and the patient was discharged from the hospital on the day 5. We also review the literature on interesting extra-abdominal migrations of swallowing foreign bodies

Primary aortoesophageal fistula: a rare cause of acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding is a potentially life-threateningemergency, especially in the elderly. This condition accounts for approximately1% of all emergency room admissions. Among the causes of such bleedingis aortoesophageal fistula, a dreaded but apparently rare condition, firstrecognized in 1818. The great majority of cases are of primary aortoesophagealfistula, caused by atheromatous aortic aneurysms or, less frequently, bypenetrating aortic ulcer. The clinical presentation of aortoesophageal fistulais typically characterized by the so-called Chiari’s triad, consisting of thoracicpain followed by herald bleeding, a variable, short symptom-free interval,and fatal exsanguinating hemorrhage. The prognosis is poor, the in-hospitalmortality rate being 60%. Conservative treatment does not prolong survival,and the in-hospital mortality rate is 40% for patients submitted to conventionalsurgical treatment. Here, we report the case of a 93-year-old woman whopresented to the emergency room with a history of hematemesis. The patientwas first submitted to upper gastrointestinal endoscopy, the findings of whichwere suggestive of aortoesophageal fistula. The diagnosis was confirmedby multidetector computed tomography of the chest. Surgery was indicated.However, on the way to the operating room, the patient presented with massivebleeding and went into cardiac arrest, which resulted in her death

Fish bone foreign body disease : a case with dramatic complication

Fish bone is the commonest cause of foreign body disease in Asian population. Esophageal perforation following fish bone foreign body accounts for 1-4% of the total reported cases. A 60-year-old lady presented with progressively worsening dysphagia and odynophagia over five days period following a fish meal. She sought treatment at two general practitioner clinic and a private hospital before being referred to Ear, Nose and Throat specialist. Repeated neck X-ray revealed a significant increase in prevertebral soft tissue thickness with large air-pocket tracking, small opacity at the prevertebral C3 level and subcutaneous emphysema anterior to the neck suggestive of retropharyngeal hematoma or abscess. A CT neck and thorax showed a 2.1 cm linear dense structure at the level of C7/T1 that appeared to protrude outside the esophagus in between the tracheoesophageal space. Direct laryngoscopy and repeat emergency esophagoscopy revealed a perforation at the right side of esophagus distal to cricopharyngeus with pus discharge upon milking of posterior lateral wall and a fish bone measuring 3.0 x 0.5 cm was removed from posterior wall of esophagus 17 cm from incisor. Gastrograffin study on day 10 was normal and was discharged on day 11 with Ryle’s tube feeding and to complete oral antibiotic. Fiber optic endoscopic evaluations of swallowing at two weeks follow up was normal. Subsequent review in the clinic showed full recovery without sequelae. Migrating fish bone can lead to esophagus penetration with serious complications. Mortality and morbidity from fish bone foreign body can be minimized with early diagnosis, referral and removal

Case report: Aortoesophageal fistula—an extremely rare but life-threatening cardiovascular cause of hematemesis

Aortoesophageal fistula (AEF) is an extremely rare cardiovascular etiology of hematemesis and upper gastrointestinal bleeding. As such, its recognition and diagnosis are challenging and may be delayed when such patients present to the emergency department (ED). Without timely surgical intervention, AEF is almost always fatal. Awareness of AEF as a possible diagnosis and consequently early identification of these patients presenting to the ED are therefore crucial in optimizing clinical outcomes. We report a 45-year-old male presenting to the ED with the classical triad of an AEF (Chiari's triad)—midthoracic pain or dysphagia, a sentinel episode of minor hematemesis, then massive hematemesis with risk of exsanguination. The case report highlights the importance of considering the differential diagnosis of AEF when evaluating patients presenting to the ED with hematemesis, especially if they have predisposing risk factors such as prior aortic or esophageal surgeries, aortic aneurysms, or thoracic malignancies. Patients suspected of having AEF should be prioritized for early computed tomography angiography to expedite diagnosis and treatment

Infected Aortic Aneurysms

Infected aortic aneurysms are surgical urgencies, requiring prompt management to avoid the development of catastrophic complications. Although traditional open surgery composed of radical debridement and aortic reconstruction remains the gold-standard, many favorable results of the endovascular repair strategy have been reported. In this chapter, the etiology, bacteriology, clinical manifestation, and diagnostic criteria of infected aortic aneurysms will be discussed in detail at first, followed by a comprehensive review of both traditional open surgery and endovascular repair, based on current evidences and the authors’ institutional experience. Along with long-term oral antibiotic suppression and aggressive adjunctive procedures, endovascular repair for uncomplicated infected aortic aneurysms could be a definite treatment alternative to traditional open surgery in the endovascular era

Conservative management of oesophageal soft food bolus impaction

Background: Impaction of a soft food bolus in the oesophagus causes dysphagia and regurgitation. If the bolus does not pass spontaneously, then the patient is at risk of aspiration, dehydration, perforation, and death. Definitive management is with endoscopic intervention, recommended within 24 hours. Prior to endoscopy, many patients undergo a period of observation, awaiting spontaneous disimpaction, or may undergo enteral or parenteral treatments to attempt to dislodge the bolus. There is little consensus as to which of these conservative strategies is safe and effective to be used in this initial period, before resorting to definitive endoscopic management for persistent impaction. Objectives: To evaluate the efficacy of non-endoscopic conservative treatments in the management of soft food boluses impacted within the oesophagus. Search methods: We searched the following databases, using relevant search terms: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and CINAHL. The date of the search was 18 August 2019. We screened the reference lists of relevant studies and reviews on the topic to identify any additional studies. Selection criteria: We included randomised controlled trials of the management of acute oesophageal soft food bolus impaction, in adults and children, reporting the incidence of disimpaction (confirmed radiologically or clinically by return to oral diet) without the need for endoscopic intervention. We did not include studies focusing on sharp or solid object impaction. Data collection and analysis: We used standard methodological procedures recommended by Cochrane. Main results: We identified 890 unique records through the electronic searches. We excluded 809 clearly irrelevant records and retrieved 81 records for further assessment. We subsequently included one randomised controlled trial that met the eligibility criteria, which was conducted in four Swedish centres and randomised 43 participants to receive either intravenous diazepam followed by glucagon, or intravenous placebos. The effect of the active substances compared with placebo on rates of disimpaction without intervention is uncertain, as the numbers from this single study were small, and the rates were similar (38% versus 32%; risk ratio 1.19, 95% confidence interval 0.51 to 2.75, P = 0.69). The certainty of the evidence using GRADE for this outcome is low. Data on adverse events were lacking. Authors' conclusions: There is currently inadequate data to recommend the use of any enteral or parenteral treatments in the management of acute oesophageal soft food bolus impaction. There is also inadequate data regarding potential adverse events from the use of these treatments, or from potential delays in definitive endoscopic management. Caution should be exercised when using any conservative management strategies in these patients.This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.published versio