Case Study

Carotid-esophageal fistula due to a retained foreign body

Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(8) 984–986 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313502210 aan.sagepub.com

Samad Behesthirouy and Farzad Kakaei

Abstract We describe a case of carotid-esophageal fistula due to retention of an ingested foreign body in a 65-year-old woman. Late diagnosis resulted in severe hemorrhage and postoperative cerebrovascular accident because of the impossibility of repairing the carotid artery due to severe local inflammation.

Keywords Carotid artery injuries, Esophageal fistula, Foreign bodies, Hematemesis, Hemorrhage, Stroke

Introduction Massive hematemesis due to a fistula between the esophagus and neck great vessels is usually due to local invasion and erosion by pharyngeal or esophageal malignant tumors. It is an emergency condition with high mortality and morbidity. Other benign conditions such as penetrating trauma or esophageal foreign bodies may cause the same problem which should be promptly treated before the development of massive uncontrollable hemorrhage. Such benign conditions usually present in younger and healthier people without associated comorbidities, and should be treated before the onset of more complications. We describe a case of carotid-esophageal fistula due to a foreign body, which was associated with severe hemorrhage and postoperative cerebrovascular accident because of the impossibility of carotid artery repair the due to severe local inflammation.

Case report A 65-year-old woman experienced dysphagia after her dinner which included a small amount of bread. She felt that a foreign body had been retained in her throat, and consulted an otorhinolaryngologist. Direct pharyngoscopy revealed nothing except mild local erythema. A fiberoptic pharyngoesophageal examination was recommended, but the patient declined. Dysphagia continued, associated with pain in the left side of the neck. Three 3 weeks later, she suffered hematemesis after

eating her lunch. The bleeding was severe and pulsatile, but stopped spontaneously. She was referred to our emergency room. Her vital signs were stable with mild tachycardia (pulse rate 90 beatsmin 1) and no orthostatic hypotension. Her initial hemoglobin level was 9.0 gdL 1 and a leukocyte count was 12000/mm3 (80% polymorphonuclear cells). Laboratory tests were normal. Head and neck examination revealed mild bulging of the left side of the neck with tenderness, but no lymphadenopathy, ecchymosis, or bruit on auscultation. She was admitted for upper gastrointestinal endoscopy which was negative except for a small amount of old blood in the stomach. The endoscopist did not notice the mild bulging of the neck, a foreign body, or inflammation on the left side of the upper esophagus, probably because the patient’s chief complaint: ‘‘neck pain with dysphagia after foreign body ingestion’’ was not noticed. Eventually, neck anteroposterior and lateral radiographs were requested by the internal medicine resident, which revealed a transverse-lying tiny steal wire in the left side of the neck. A surgeon was consulted and neck computed tomography was requested for better localization of the foreign body. After obtaining the scan, severe hematemesis

Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran Corresponding author: Farzad Kakaei, MD, Surgery Group, Imam Reza Hospital, Golgasht St., Tabriz, Iran. Email: [email protected]

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occurred with associated hemorrhagic shock. The patient was immediately transferred to the operating room, and a serum and blood transfusion was started. Under general anesthesia, rigid esophagoscopy revealed a very small ulcer but no frank bleeding at the left pharyngoesophageal junction. The blood pressure became stable on simultaneous infusion of 2 L of normal saline and 2 units of packed red blood cells. The preoperative hemoglobin level was 6.0 gdL 1. A standard anterior left sternocleidomastoid incision was performed at an acceptable distance from the upper neck bulging, to control the large neck blood vessels, but sudden bleeding obscured the surgical field. The bleeding was controlled by finger packing, and the incision was extended to an upper sternotomy to control the proximal carotid without stopping the bleeding from the distal carotid stump. All tissues were severely inflamed and distal control was very difficult and associated with severe arterial bleeding. Four more units of packed red blood cells were transfused to stabilize the patient. After removing all blood clots and necrotic tissues, the distal stump was controlled before the carotid bifurcation. Because of severe infected inflammation, no reconstruction was possible, and both proximal and distal ends were ligated. A tiny steal wire was found protruding from the lateral wall of the esophagus and penetrating the completely disrupted carotid artery. The jugular vein was inflamed but intact, and the tiny hole in the laryngal-esophageal junction needed no repair. A Penrose drain was inserted and the incision was repaired after irrigation. The patient was transferred to the intensive care unit and full-dose heparin was started for prevention of cerebrovascular thrombotic accident, but right-sided hemiparesis was not preventable, which was associated with dysphasia. The drain was removed after 7 days, intravenous broad spectrum antibiotics were continued for 2 weeks, and she was discharged. Three months later, she was stable with no signs of wound infection. Most of the hemiparesis improved on physiotherapy, but her mild dysphasia had not recovered.

Discussion Hematemesis has a wide range of differential diagnoses, from benign mucosal tears due to severe vomiting to severe bleeding caused by ruptured esophageal varices secondary to portal hypertension. Association of this symptom with acute oropharyngeal dysphagia will narrow this range.1 Usually, this type of dysphagia in the elderly is a symptom of a benign or malignant tumor in or near the esophagus; severe hematemesis is due to erosion of the tumor into the aorta or neck great vessels, with a grave prognosis due to

exsanguinating hemorrhage. Benign diseases such as neurologic disorders, Zenker’s diverticulum, progressive systemic sclerosis, webs and rings, fungal infections, esophagitis due to reflux, or corrosive agents may cause progressive oropharyngeal dysphagia, but rarely cause severe upper gastrointestinal bleeding.2 One of the most important causes of this type of dysphagia is a retained foreign body. Ingested foreign bodies are usually retained at a site of physiological narrowing such as the pharyngoesophageal junction. Most foreign bodies (with sharp or blunt boundaries) are amenable to endoscopic (flexible or rigid) removal without a major complication, but only if diagnosed early and the patient is referred early for removal. As in our case, any delay in diagnosis may result in devastating complications due to erosion of the object through the esophageal wall into vital structures of the neck. Deep neck or para- or retropharyngeal infections or abscess, mediastinitis, and erosion into the large neck vessels are among these complications. Erosion into the carotid artery is very rare, and most reported carotid-esophageal fistulas are due to carcinoma.3 Other etiologies include previous esophagectomy, tracheal surgery, esophageal stent erosion, penetrating trauma, and nasogastric intubation.4–9 Whatever the cause, prompt diagnosis and treatment is needed for such a life-threatening complication. If diagnosed during flexible endoscopy, immediate balloon tamponade and transfer to the operating room may be life-saving.9 If the bleeding stops spontaneously and the patient stabilizes, angiographic interventions (angioembolization) may stop the bleeding at least temporarily before surgical treatment.4 Angiography in stable patients may reveal the site of bleeding and help plan the best approach for distal and proximal control of the carotid artery. Unfortunately, as in our patient, local inflammation may be so severe that any surgical approach to control the carotid artery before entering the perforated area may be fruitless and associated with brisk bleeding. Even a median sternotomy for proximal carotid control could not completely stop the bleeding in our patient because of back-bleeding from the distal stump. Transferring a Fogarty catheter through a small proximal arteriotomy to the distal site, and inflation of its balloon to occlude the distal carotid artery, may reduce the bleeding. Anatomic repair in this condition may be impossible due to severe inflammation. If repair is possible, a muscle flap from an adjacent strap or sternocleidomastoid muscle should be inserted between the esophagus and the carotid artery. Ligation is the best choice, but if the distal carotid stump pressure is less than 60 mm Hg, it will result in ischemic stroke in most cases. Full-dose heparinization may prevent this complication at least partially, as in our case.

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Asian Cardiovascular & Thoracic Annals 22(8) Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest statement None declared

References

Figure 1. Computed tomography of the neck showing the metal foreign body in the left side of the neck, protruding from the esophagus.

1. American Gastroenterological Association medical position statement on management of oropharyngeal dysphagia. Gastroenterology 1999;116:452–4. 2. Rubesin SE. Oral and pharyngeal dysphagia [Review]. Gastroenterol Clin North Am 1995; 24: 331–352. 3. Emamy H and Mehzad M. Carotidoesophageal fistula complicating carcinoma of the esophagus: report of a case. Am Surg 1976; 42: 376–378. 4. Pucher P, Kashef E, Woods C, Livingstone J and Zacharakis E. Life-threatening bleeding from arterialoesophageal fistula following oesophagectomy. Updates Surg 2013; 65: 149–152. 5. Das P, Zhu H, Shah RK, Roberson DW, Berry J and Skinner ML. Tracheotomy-related catastrophic events: results of a national survey. Laryngoscope 2012; 122: 30–37. 6. Ali AT, Kokoska MS, Erdem E and Eidt JF. Esophageal stent erosion into the common carotid artery. Vasc Endovascular Surg 2007; 41: 80–82. 7. Levine EA and Alverdy JC. Carotid-esophageal fistula following a penetrating neck injury: case report. J Trauma 1990; 30: 1588–1590. 8. Garrigues B and Kiegel P. Carotido-esophageal fistula: an unusual complication of nasogastric intubation? Ann Fr Anesth Reanim 1988; 7: 438. 9. Ramos MA and Nord HJ. Carotid-esophageal fistula treated with balloon tamponade and surgery. Gastrointest Endosc 2000; 52: 292–293.

Figure 2. Computed tomography of the neck showing the foreign body near the carotid artery wall, with air around it.

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Carotid-esophageal fistula due to a retained foreign body.

We describe a case of carotid-esophageal fistula due to retention of an ingested foreign body in a 65-year-old woman. Late diagnosis resulted in sever...
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