Sam is in and out in what seems hardly a minute. He has extracted the offending earpiece! Triumphantly he holds it high for all to see, and everyone applauds and laughs with relief. The baby dolphin slips smoothly out of the trestle and heads immediately for its mother's side.
Addendum furnished, upon request, by the writer's husband: Because of the extraordinary circumstances under which this procedure had to be done, no photographic documentation or particular attention to anatomic landmarks were made. The entire procedure, of necessity, took a total time of approximately 90 seconds. The endoscopic view of the stomach of the bottlenose dolphin (Tursiopssp.) was not dissimilar from that of man. A moderate amount of pinkishcolored milk was noted in the lower end of the stomach. The plastic, eyeglass earpiece was seen protruding from the milky mass. A Cameron-Miller electrocautery snare was passed through the biopsy channel of an Olympus GIF panendoscope, and the offending object was lassoed and extracted. A dolphin's stomach is composed of 3 separate chambers. The upper portion, that which was endoscopically visualized, represents a dilatation of the distal esophagus which functions as a storage organ (the forestomach). The second and third portions of the stomach constitute the true stomach. REFERENCE 1. RIDGWAY SH: Mammals of the Sea. Springfield, Charles C Thomas, 1972
Esophageal perforation by swallowed foreign body causing arterial fistula with gastrointestinal hemorrhage Lawrence R. McCormack, MD Lee S. Monroe, MD* Division of Gastroenterology Hospital of Scripps Clinic La Jolla, California
Perforation of the esophagus by a swallowed foreign body with formation of a fistula between the esophagus and a major artery is an uncommon cause of gastrointestinal hemorrhage. The majority of such cases have involved perforation of the aorta and exsanguinating hemorrhage.1-7 Esophageal fistulas of other types are rare. For example, only 1 case of fistula between the esophagus and common carotid artery has been reported in the recent English literature. 8 We herewith report a case of foreign body ingestion, in this case a chicken bone, causing a fistula between the esophagus and the lingual artery which led to life-threatening gastrointestinal hemorrhage. CASE REPORT An 80-year-old woman was admitted to the Hospital of Scripps Clinic on 17 February 1976 because of odynophagia for 1 week and melena for 18 hours. Except for a ·Reprint requests: Lee S. Monroe, MD, Division of Gastroenterology, Hospital of Scripps Clinic, La Jolla, California 92037.
VOLUME 23, NO.3, 1977
Figure 1. Esophagoarterial fistula as seen at esophagoscopy. history of peptic ulcer many years ago, she claimed to have been entirely well until, while eating a chicken, a bone became painfully lodged in her throat. The patient went to her local emergency room where an esophagogram was said to be normal, and she was reassured. However, she continued to experience discomfort in the left side of her throat with swallowing, and she resorted to ingesting only liquid foods as swallowing solids aggravated her odynophagia. She gradually developed mild upper abdominal pain and nausea. At8 pm on the day before admission, the patient passed the first of a series of loose, tarry stools. Examination disclosed an elderly, lethargic, white female with a blood pressure of 140/60 and a pu Ise of 96. There was no evidence of crepitus in the neck or mediastinal emphysema. The abdomen was diffusely tender without masses or organomegaly. Rectal examination yielded black, tarry stool. The initial hemoglobin of 8.8 g subsequently dropped to 7.9 g; the BUN was 44 mg. Nasogastric aspiration disclosed blood which cleared with saline lavage of the stomach. The patient was transfused with 2 units of blood and plasma. Gastroscopy was performed the next day. The gastric and duodenal mucosa was intact. On withdrawi ng the instrument into the upper esophagus, at approximately 15 cm, a 1 cm tear in the mucosa was noted (Figure 1). Upon biopsy of the area with forceps, a small amount of purulent material and blood clot was released. Active bleeding was not seen. The biopsy specimens included acutely inflamed granulation tissue, fibrinopurulent debris, and inflamed striated muscle. A barium swallow (Figure 2) and xerogram of the neck subsequently showed a 4 mm density adjacent to the posterior wall of the cervical esophagus at the C7-T1 level. Early in the morning of the fourth hospital day, the patient developed nausea and passed a large, tarry stool. The systolic blood pressure dropped to 80. With saline infused intravenously, the blood pressure rose to 96/60. The hemoglobin
Figure 2. Barium swallow disclosing an esophageal wall defect at the site of the chicken bone perforation (arrow). 157
dropped from 9.4 g to 6.9 g after infusion. Iced saline lavage failed to halt the bleeding, and the patient was given 20 units of vasopressin intravenously over 10 minutes. Evidence of active bleeding ceased, and her vital signs stabi lized. She was transfused with 4 units of blood, restoring her hemoglobin to 9.6 g, and she was taken to the operating room. Rigid esophagoscopy under anesthesia again disclosed the esophageal lesion which bled readily. At exploration of the neck, an esophageal perforation 0.5 cm in diameter was seen on the left lateral wall at the level of the inferior cornu of the thyroid cartilage. The perforation extended into the lingual branch of the external carotid artery, creating an esophagoarterial fistula. The lingual artery was ligated, and the esophageal wall defect repaired. No foreign material was identified at the time of operation. The postoperative course was uneventful. The patient is alive and well 7 months after operation. DISCUSSION Gastrointestinal hemorrhage is an uncommon complication of esophageal perforation consequent to swallowing a foreign object. Kozarzewski> described bleeding as a complication in only 4 of 433 cases. Frank gastrointestinal hemorrhage from a foreign body perforation of the esophagus has been, in most reported cases, secondary to fistula involving the aorta. We report what we find to be only the second case in the recent English literature of bleeding esophagoarterial fistula involving a neck vessel. The other report" described a patient who developed a large false aneurysm of the common carotid artery caused by a fish bone perforation of the esophagus. This patient did well after surgical intervention, as did ours, in contrast to the bleak prognosis in patients with aorta-esophageal fistulas. In a review of 80 cases of aorta-esophageal fistulas secondary to foreign body ingestion, Barrie and Townrow ' described the classic clinical findings of this entity. Most of the patients experienced initial discomfort on swallowing, followed by either continued odynophagia or a symptom-free
interval of several days. In most cases an early hemorrhage occurred which was self-limited and controlled medically. This "signal" hemorrhage preceded the major fatal hemorrhage by 2 hours to 3 days, averaging 1 day. Our patient presented with a severe gastrointestinal hemorrhage which stopped spontaneously and recurred 3 days later. The second hemorrhage was not self-limited and was controlled only with the use of intravenous vasopressin. The radiographic and endoscopic findings were good clues as to the patient's true diagnosis, yet optimism after her initial bleeding stopped delayed surgical intervention until the second episode of bleeding occurred. Thus, our patient, in conformity with the previously described syndrome, presented with a "signal" hemorrhage followed by bleeding much more difficult to control. The intermittency of hemorrhage from esophago-arterial fistulas has been ascribed to decreased blood pressure or spasm of the arterial wall,' tamponade effect of blood in the esophagus,3 and spasm of the bowel wal1. 9 Renewed bleeding could be caused by disruption of the initial clot by infection, as in our case, or by mechanical factors. REFERENCES 1. BARRIE Hj, TOWN ROW V: Perforation of the aorta by a foreign body in
esophagus. 1 Laryngol 61: 38, 1946 2. KOZARZEWSKI Z, ZYGADLOWSKI j: Aortic hemorrhages as a complication of
resilient foreign bodies in the esophagus. Oto/aryngol Polska 26:39, 1972 3. HENRY Wj, MISCALL L: Aortic-esophageal fistula. 1Thorac Cardiovasc Surg
39:258, 1960 4. BANK RS: Fatal aortic-esophageal fistula from a swallowed fish bone. lAMA
122:1011,1943 5. MATHEWSON C jR, DOZIER WE, HAMILLjP, SMITH M: Clinical experiences
with perforation of the esophagus. Am 1 Surg 104:257, 1962 6. HARDIN Wj, HARDY jD, CONN jH: Esophageal perforations. Surg Gynecol
Obstet 124:325, 1967 7. SCHRAMEK A, WEISZ GM, ERLIK 0: Gastro-intestinal bleeding due to
arterio-enteric fistula. Digestion 4:103, 1971 8. STOLZ jL, CHAMORRO H, ARGER PH: Fish bone fistulae. Arch Oto/aryngol
101 :252, 1975 9. FERGUSON Mj, ARDEN Mj: Gastrointestinal hemorrhage secondary to rup-
ture of aorta. Arch Intern Med 117:133, 1966
Histoplasmosis presenting as an esophageal tumor
Richard P. Schneider, MD* William Edwards, MD Division of Gastroenterology Department of Medicine and the Department of Surgery S1. Thomas Hospital and Vanderbilt University Medical School Nashville, Tennessee
Ulcerated tumors of the esophagus may be leiomyomas, carcinomas, or metastatic tumors, such as melanoma. Mediastinal tumors or nodes may push into the esophagus and cause secondary ulceration of the mucosa. This report presents a patient who presented with an ulcerated esophageal tumor caused by a mediastinal node infected with Histoplasma capsulatum. The patient was cured by surgical resection of the node and has remained weil. 'Reprint requests: Richard Schneider, MD, Box 380, 51. Thomas Hospital, Nashville, Tennessee 37202.
158
CASE REPORT A 15-year-old boy was referred because of recent dysphagia and odynophagia. He had been in excellent health until 4 days earlier when he first experienced difficult, painful swallowing. On examination he appeared to be a healthy young man and had no abnormal physical findings. Laboratory tests were all normal. First-strength PPD was negative. Fungal serology and skin tests were not obtained. A chest radiograph revealed an ill-defined, irregular density in the right lower lobe. A barium swallow showed a narrowing in the mid-esophagus (Figure 1). Esophagoscopy revealed a subGASTROINTESTINAL ENDOSCOPY
Addendum furnished, upon request, by the writer's husband: Because of the extraordinary circumstances under which this procedure had to be done, no photographic documentation or particular attention to anatomic landmarks were made. The entire procedure, of necessity, took a total time of approximately 90 seconds. The endoscopic view of the stomach of the bottlenose dolphin (Tursiopssp.) was not dissimilar from that of man. A moderate amount of pinkishcolored milk was noted in the lower end of the stomach. The plastic, eyeglass earpiece was seen protruding from the milky mass. A Cameron-Miller electrocautery snare was passed through the biopsy channel of an Olympus GIF panendoscope, and the offending object was lassoed and extracted. A dolphin's stomach is composed of 3 separate chambers. The upper portion, that which was endoscopically visualized, represents a dilatation of the distal esophagus which functions as a storage organ (the forestomach). The second and third portions of the stomach constitute the true stomach. REFERENCE 1. RIDGWAY SH: Mammals of the Sea. Springfield, Charles C Thomas, 1972
Esophageal perforation by swallowed foreign body causing arterial fistula with gastrointestinal hemorrhage Lawrence R. McCormack, MD Lee S. Monroe, MD* Division of Gastroenterology Hospital of Scripps Clinic La Jolla, California
Perforation of the esophagus by a swallowed foreign body with formation of a fistula between the esophagus and a major artery is an uncommon cause of gastrointestinal hemorrhage. The majority of such cases have involved perforation of the aorta and exsanguinating hemorrhage.1-7 Esophageal fistulas of other types are rare. For example, only 1 case of fistula between the esophagus and common carotid artery has been reported in the recent English literature. 8 We herewith report a case of foreign body ingestion, in this case a chicken bone, causing a fistula between the esophagus and the lingual artery which led to life-threatening gastrointestinal hemorrhage. CASE REPORT An 80-year-old woman was admitted to the Hospital of Scripps Clinic on 17 February 1976 because of odynophagia for 1 week and melena for 18 hours. Except for a ·Reprint requests: Lee S. Monroe, MD, Division of Gastroenterology, Hospital of Scripps Clinic, La Jolla, California 92037.
VOLUME 23, NO.3, 1977
Figure 1. Esophagoarterial fistula as seen at esophagoscopy. history of peptic ulcer many years ago, she claimed to have been entirely well until, while eating a chicken, a bone became painfully lodged in her throat. The patient went to her local emergency room where an esophagogram was said to be normal, and she was reassured. However, she continued to experience discomfort in the left side of her throat with swallowing, and she resorted to ingesting only liquid foods as swallowing solids aggravated her odynophagia. She gradually developed mild upper abdominal pain and nausea. At8 pm on the day before admission, the patient passed the first of a series of loose, tarry stools. Examination disclosed an elderly, lethargic, white female with a blood pressure of 140/60 and a pu Ise of 96. There was no evidence of crepitus in the neck or mediastinal emphysema. The abdomen was diffusely tender without masses or organomegaly. Rectal examination yielded black, tarry stool. The initial hemoglobin of 8.8 g subsequently dropped to 7.9 g; the BUN was 44 mg. Nasogastric aspiration disclosed blood which cleared with saline lavage of the stomach. The patient was transfused with 2 units of blood and plasma. Gastroscopy was performed the next day. The gastric and duodenal mucosa was intact. On withdrawi ng the instrument into the upper esophagus, at approximately 15 cm, a 1 cm tear in the mucosa was noted (Figure 1). Upon biopsy of the area with forceps, a small amount of purulent material and blood clot was released. Active bleeding was not seen. The biopsy specimens included acutely inflamed granulation tissue, fibrinopurulent debris, and inflamed striated muscle. A barium swallow (Figure 2) and xerogram of the neck subsequently showed a 4 mm density adjacent to the posterior wall of the cervical esophagus at the C7-T1 level. Early in the morning of the fourth hospital day, the patient developed nausea and passed a large, tarry stool. The systolic blood pressure dropped to 80. With saline infused intravenously, the blood pressure rose to 96/60. The hemoglobin
Figure 2. Barium swallow disclosing an esophageal wall defect at the site of the chicken bone perforation (arrow). 157
dropped from 9.4 g to 6.9 g after infusion. Iced saline lavage failed to halt the bleeding, and the patient was given 20 units of vasopressin intravenously over 10 minutes. Evidence of active bleeding ceased, and her vital signs stabi lized. She was transfused with 4 units of blood, restoring her hemoglobin to 9.6 g, and she was taken to the operating room. Rigid esophagoscopy under anesthesia again disclosed the esophageal lesion which bled readily. At exploration of the neck, an esophageal perforation 0.5 cm in diameter was seen on the left lateral wall at the level of the inferior cornu of the thyroid cartilage. The perforation extended into the lingual branch of the external carotid artery, creating an esophagoarterial fistula. The lingual artery was ligated, and the esophageal wall defect repaired. No foreign material was identified at the time of operation. The postoperative course was uneventful. The patient is alive and well 7 months after operation. DISCUSSION Gastrointestinal hemorrhage is an uncommon complication of esophageal perforation consequent to swallowing a foreign object. Kozarzewski> described bleeding as a complication in only 4 of 433 cases. Frank gastrointestinal hemorrhage from a foreign body perforation of the esophagus has been, in most reported cases, secondary to fistula involving the aorta. We report what we find to be only the second case in the recent English literature of bleeding esophagoarterial fistula involving a neck vessel. The other report" described a patient who developed a large false aneurysm of the common carotid artery caused by a fish bone perforation of the esophagus. This patient did well after surgical intervention, as did ours, in contrast to the bleak prognosis in patients with aorta-esophageal fistulas. In a review of 80 cases of aorta-esophageal fistulas secondary to foreign body ingestion, Barrie and Townrow ' described the classic clinical findings of this entity. Most of the patients experienced initial discomfort on swallowing, followed by either continued odynophagia or a symptom-free
interval of several days. In most cases an early hemorrhage occurred which was self-limited and controlled medically. This "signal" hemorrhage preceded the major fatal hemorrhage by 2 hours to 3 days, averaging 1 day. Our patient presented with a severe gastrointestinal hemorrhage which stopped spontaneously and recurred 3 days later. The second hemorrhage was not self-limited and was controlled only with the use of intravenous vasopressin. The radiographic and endoscopic findings were good clues as to the patient's true diagnosis, yet optimism after her initial bleeding stopped delayed surgical intervention until the second episode of bleeding occurred. Thus, our patient, in conformity with the previously described syndrome, presented with a "signal" hemorrhage followed by bleeding much more difficult to control. The intermittency of hemorrhage from esophago-arterial fistulas has been ascribed to decreased blood pressure or spasm of the arterial wall,' tamponade effect of blood in the esophagus,3 and spasm of the bowel wal1. 9 Renewed bleeding could be caused by disruption of the initial clot by infection, as in our case, or by mechanical factors. REFERENCES 1. BARRIE Hj, TOWN ROW V: Perforation of the aorta by a foreign body in
esophagus. 1 Laryngol 61: 38, 1946 2. KOZARZEWSKI Z, ZYGADLOWSKI j: Aortic hemorrhages as a complication of
resilient foreign bodies in the esophagus. Oto/aryngol Polska 26:39, 1972 3. HENRY Wj, MISCALL L: Aortic-esophageal fistula. 1Thorac Cardiovasc Surg
39:258, 1960 4. BANK RS: Fatal aortic-esophageal fistula from a swallowed fish bone. lAMA
122:1011,1943 5. MATHEWSON C jR, DOZIER WE, HAMILLjP, SMITH M: Clinical experiences
with perforation of the esophagus. Am 1 Surg 104:257, 1962 6. HARDIN Wj, HARDY jD, CONN jH: Esophageal perforations. Surg Gynecol
Obstet 124:325, 1967 7. SCHRAMEK A, WEISZ GM, ERLIK 0: Gastro-intestinal bleeding due to
arterio-enteric fistula. Digestion 4:103, 1971 8. STOLZ jL, CHAMORRO H, ARGER PH: Fish bone fistulae. Arch Oto/aryngol
101 :252, 1975 9. FERGUSON Mj, ARDEN Mj: Gastrointestinal hemorrhage secondary to rup-
ture of aorta. Arch Intern Med 117:133, 1966
Histoplasmosis presenting as an esophageal tumor
Richard P. Schneider, MD* William Edwards, MD Division of Gastroenterology Department of Medicine and the Department of Surgery S1. Thomas Hospital and Vanderbilt University Medical School Nashville, Tennessee
Ulcerated tumors of the esophagus may be leiomyomas, carcinomas, or metastatic tumors, such as melanoma. Mediastinal tumors or nodes may push into the esophagus and cause secondary ulceration of the mucosa. This report presents a patient who presented with an ulcerated esophageal tumor caused by a mediastinal node infected with Histoplasma capsulatum. The patient was cured by surgical resection of the node and has remained weil. 'Reprint requests: Richard Schneider, MD, Box 380, 51. Thomas Hospital, Nashville, Tennessee 37202.
158
CASE REPORT A 15-year-old boy was referred because of recent dysphagia and odynophagia. He had been in excellent health until 4 days earlier when he first experienced difficult, painful swallowing. On examination he appeared to be a healthy young man and had no abnormal physical findings. Laboratory tests were all normal. First-strength PPD was negative. Fungal serology and skin tests were not obtained. A chest radiograph revealed an ill-defined, irregular density in the right lower lobe. A barium swallow showed a narrowing in the mid-esophagus (Figure 1). Esophagoscopy revealed a subGASTROINTESTINAL ENDOSCOPY
