Unusual cause for dysphagia: perforation of the proximal esophagus by a toothpick

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We report an unusual case of dysphagia of a 65-year-old patient caused by the perforation of the proximal esophagus by an accidentally swallowed toothpick.

The patient presented at our emergency unit with increased dysphagia and retrosternal pain for the past 6 days. The consumption of solid food had not been possible for the past 3 days. Swallowing liquids induced retrosternal pain. Choking on a solid piece of food or accidentally swallowing a foreign body was denied. The symptoms had started shortly after his last solid meal 6 days previously. The laboratory results showed elevated C-reactive protein levels (11.6 mg/dl) and an elevated lactate dehydrogenase of 348 U/l. The patient reported no medical history and no current medication. A computed tomography scan showed multiple enlarged lymph nodes near the maxilla and a solid tissue formation in the posterior mediastinum. Below this tumor, a local thickness of the esophagus was noticed accompanied by pathologic contrast medium-enhancement of the wall. Moreover, multiple enlarged lymph nodes peritracheal were detected ([Fig. 1]). The patient was suspected of having of an esophageal tumor and was referred to our unit for upper gastrointestinal endoscopy. The endoscopy showed, at 20 cm below the alignment, the orifice of a fistula surrounded by fibrin-covered tissue and inflammation up to 17 cm ([Fig. 2 a]). No signs of a tracheo-esophageal fistula were seen. For further histological examination, a biopsy from the region of the fistula orifice was taken, during which a toothpick was discovered and endoscopically removed ([Fig. 2 b]).

Under parenteral nutrition and antibiotic therapy for several days the patient improved rapidly, and a control computed tomography scan and upper gastrointestinal endoscopy showed only small areas of residual inflammation.

There are several case reports in the literature reporting ingestion of a toothpick as the cause for perforation of the stomach, duodenum or even the colon [1] [2] [3], but so far no reports describing an esophageal perforation have been published.

Fig. 1 Oblique coronal multiplanar reconstruction (MPR) image from 64-slice multidetector computed tomography (MDCT) scan of a patient with esophageal perforation. The true lumen of the esophagus (asterisk), extraluminal free air (arrow), and inflammatory changes in the mediastinum (arrowhead) are identified.

Fig. 2  Endoscopic view of the fistula orifice 20 cm below the alignment. b The toothpick after taking a biopsy of the lesion and removal of the forceps.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH

References

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• 2 Serwe S, Weber J, Strock P, Lens V. Liver abscess caused by an unnoticed swallowed toothpick perforating the colonic wall.  Z Gastroenterol. 2007;  45 1060-1062
• 3 Wichmann M W, Hüttl T P, Billing A, Jauch K W. Laparoscopic management of a small bowel perforation caused by a toothpick.  Surg Endosc. 2004;  18 717-718