Teaching Case

A 72-year-old male Nursing Home Resident, was admitted with a queried upper gastrointestinal (GI) bleed. He had an underlying communication deficit and therefore, was unable to provide further information. The differential provided by the admitting medical team was a GI bleed and queried aspiration subsequently.

Chest X-ray (Figure 1) on admission in the Emergency Department (ED), showed a patchy opacification of the right lung base. This was suggestive of aspiration pneumonia. Of note, it was reported that a religious jewellery artefact was projecting over the lower mediastinum. This artefact was not confirmed to being worn by the patient and this was overlooked by the radiology staff at the initial chest imaging. Subsequently, the medical team repeated the chest X-ray the next day. This confirmed an ingested foreign body, a religious crucifix and rosary beads, lying superiorly to the lower oesophageal sphincter (LOS).

Background

The incidence of a foreign body in the adult population is approximately 13 per 100,000 people. The most common cause is a food bolus, although the true incidence cannot be measured [1]. The oesophagus has three areas of narrowing anatomically, the upper oesophageal sphincter (UOS), where the oesophagus crosses the aortic arch and the LOS. In adults, approximately 68% of all obstructions occur distally. However, many presentations are not clinically detected, as these cases are more common in those with underlying mental health issues, neurological conditions, or intellectual disability [2]. Differential diagnosis at the LOS includes cancer, Schatzki ring and rarely achalasia.

Clinical Perspective

The typical presentation is one of dysphagia. However, it can mimic various clinical presentations, and this includes dyspnoea, upper GI bleeding and respiratory tract issues [3]. Imaging is crucial to assess exactly where the foreign body is, how many potential objects are involved and what potentially the object ingested is [1]. Higher risk is associated with button batteries, multiple magnets, and sharp items. Of note, button batteries can lead to severe internal burns, perforation and fistula formation, whilst magnets can cause obstruction and potential volvulus.

Outcome

Imaging not only helped to reach the correct diagnosis but was also used to plan retrieval by endoscopy. This was successful with no long-term sequelae nor perforation of the oesophagus. The oesophagus was insufflated to allow the crucifix and beads to enter the stomach, where it was bagged and retrieved (Figure 2).

Take Home Message / Teaching Points

The initial imaging showed clearly the offending foreign body, but this was not confirmed by visually inspecting the patient. This was a breakdown in communication between the technologist and radiologist. If this had been properly assessed at the time of initial imaging, diagnosis and retrieval would have been reached earlier. In the absence of effective communication from your patient, the reason for presentation can be greatly narrowed by imaging, which also can assist with the planning of effective intervention.

Written informed patient consent for publication has been obtained.