A 21-Year-Old Man With an Interesting Radiologic

Finding

A 21-year-old white man presents to the emergency department with a 10-hour history of epigastric pain that is
radiating to the chest. The pain is constant, localized, and sharp in nature. He was at a party the previous night and
admits to drinking alcoholic beverages but denies any illicit drug use. There is no associated nausea, vomiting, or
indigestion, and he denies ever having suffered from this pain in the past. The patient gives no history of shortness of
breath, palpitations, or syncope. There is no history of trauma to the epigastrium, and the patient does not remember
anything that may be causing his symptoms. His past medical history is significant for an appendectomy 9 years ago
and surgery for a deviated nasal septum 11 months ago. He is not currently on any regular medication. There is no
history of allergies. His family history is negative for any cardiac or abdominal pathology. He smokes approximately a
pack of cigarettes a day and admits to binge-drinking alcohol at weekend parties.

On examination, he appears to be alert, comfortable, and in no acute distress. He is well oriented to person, time,
and place. His vital signs reveal a heart rate of 76 bpm, a respiratory rate of 18 breaths/min, and an O2 saturation of
97% on room air. His temperature is normal. His respiratory and cardiovascular examinations reveal no abnormal
findings. The abdominal examination reveals no abnormal findings on inspection, except for a well-healed
appendectomy scar; otherwise, the abdomen is scaphoid and without any discoloration, bruises, or visible
abnormalities. Palpation reveals a slightly tender but otherwise soft epigastrium, with positive bowel sounds and no
evidence of guarding or rebound tenderness. No masses or organomegaly are appreciated, and the abdomen is
resonant to percussion, with the absence of a fluid wave or shifting dullness. The spleen and liver margins are normal
and the kidneys are not palpable. Neurologic examination is grossly normal with equal power, tone, and bulk in both
upper and lower extremities bilaterally, normal reflexes, and intact cranial nerves. His mental status exam is normal.

Laboratory investigations reveal a hemoglobin count of 16.9 g/dL (169 g/L) and a white blood cell count of 7.8 ×
103/µL (7.8 × 109/L). Urea and electrolytes are within normal limits, and there is no derangement of liver function.
Serum amylase is normal. A chest x-ray shows clear lung fields, a normal heart size, and no evidence of air under the
diaphragm; however, the chest and abdominal x-rays do reveal a radio-opaque shadow in the central lower
chest/epigastrium region. Electrocardiography shows a sinus rhythm with no evidence of ischemic changes. The
patient is instructed to take nothing orally and is placed on intravenous fluids. His symptoms are persistent, and a
repeat chest and abdominal x-ray at 12 hours post-admission shows that the previously seen shadow has not
changed position. The decision to intervene endoscopically is made.

Principio del formulario

What is the abnormality seen on the x-ray?

Hint: Take a closer look at the chest and abdominal x-rays.

External monitoring device

Radiologic artifact

Foreign-body ingestion

An implanted medical device

Final del formulario

Summary

To summarize, any esophageal foreign-body obstruction should be treated endoscopically within 24 hours. Disk
batteries pose the highest risk for caustic injury and perforation. Luminal abnormalities must be excluded at the site of
obstruction, usually through follow-up endoscopy. There is more variation in practice with respect to the management
of a foreign body that has reached the stomach. Some centers will take a liberal wait-and-watch approach for
passage of even large (0.8-2 in [2-5 cm] oval or 2.4-3.9 in [6-10 cm] long) and sharp objects. Most endoscopists,
however, will attempt removal of foreign-body obstructions larger than 0.8 in (2 cm) in circular diameter and/or more
than 2.4 in (6 cm) long, as these are deemed unlikely to pass the pyloric channel and duodenal sweep, respectively.
Sharp objects that remain in the stomach still carry a small but significant risk for complication if left untreated, and
regulatory bodies generally recommend that they be removed endoscopically if possible.[8]

Case Resolution
The patient in this case was observed for 12 hours. His symptoms did not resolve and he continued to have
epigastric and chest pain. Repeat x-rays of the chest and abdomen revealed that the foreign body had not moved
from the gastroesophageal junction. An emergency esophagogastroduodenoscopy was performed to retrieve the
bottle cap within 24 hours of the patient presenting to the ED. The metallic bottle cap was visualized at the
gastroesophageal junction, and it was pushed down into the gastric cardia before retrieval. There was no other
endoscopic abnormality of the upper gastrointestinal tract apart from associated gastritis. Initial attempts at retrieval
of the bottle cap with the large biopsy forceps failed because the cap dropped back into the stomach upon reaching
into the gastroesophageal junction. It was successfully removed with a basket net. The patient was later discharged
from the hospital and warned about the dangers of uncapping bottles with his teeth.