A two-year old female has a chief complaint of coughing up some blood. There has been a one-month history of coughing and wheezing. She has seen her pediatrician three times in the past month. The child has been treated with salbutamol liquid and amoxicillin.
Some improvement had been noted. She is currently taking amoxicillin-clavulinic acid since her symptoms did not resolve after 10 days of amoxicillin.
Up until this time, the wheezing and coughing have been mild, but tonight, her parents were alarmed because she coughed up some blood for the first time. Her parents are concerned about tuberculosis since an elderly relative suffered from this in Hong Kong.
Prior to this, there was no history of wheezing or prolonged respiratory illness.
There is no family history of wheezing.
T37.7R, P130, R44, BP 95/60, oxygen saturation in room air 99%.
She is active and alert in no acute distress. She does not appear toxic or irritable. Eyes normal. Ears normal. Oral mucosa moist. Normal pharynx and tonsils.
No hemorrhaging in the mouth noted. Neck supple. No adenopathy. Heart regular without murmurs. Lungs good aeration, mild wheezing. No retractions.
She is coughing occasionally, but the cough does not sound moist. She does not expectorate any secretions while being examined. Abdomen benign. Good color and perfusion. No bruising or petechiae noted.
A chest radiograph is obtained.
An esophageal coin is noted on the AP view. An ENT surgeon is called to extract the coin.
Further history to determine the duration that the coin may have been in the esophagus is not able to identify any episodes of choking or playing with coins. Therefore, the duration of the coin’s presence is still uncertain.
Esophageal coins come to rest at the three areas of esophageal narrowing: the cricoid, the tracheal bifurcation, and the gastroesophageal junction.
The majority of coins will become lodged in the esophagus at the level of the cricoid ring. This patient’s esophageal coin is unusual in that it is located near the tracheal bifurcation. The child is taken to the operating room where the coin is removed under general anesthesia.
At the time of removal, some hemorrhaging within the esophagus is noted. This was followed by extensive hemorrhaging and hypovolemic shock refractory to fluid and blood resuscitation. Before a vascular team could be called in, the child arrested and could not be resuscitated. Post-mortem studies identified an esophageal perforation overlying an ulcerating aortic perforation.
Teaching Points and Discussion
- The presence of an esophageal foreign body and any sign of hemorrhaging should alert one to the possibility of a vascular injury. Foreign bodies which cause vascular injury are usually sharp objects (most commonly fish or chicken bones), but coins have reportedly resulted in vascular injuries as well.
- This condition has a high mortality rate even if it is properly recognized before removal of the foreign body. The longer the foreign body remains in the esophagus, the greater the likelihood of esophageal ulceration, perforation, and extension of injury to the mediastinum, trachea, or great vessels.
- “Aorto-Esophageal” syndrome is classically described as a painful esophageal injury, followed by a symptom-free interval, then a “signal hemorrhage”, followed by hours to days until a fatal exsanguinating hemorrhage occurs. The “signal hemorrhage” which should alert one to the possibility of a vascular injury can include any sign of hemorrhage. Most typically, this manifests as hematemesis, melena, or hemoptysis. The “signal hemorrhage” may precede fatal exsanguination by hours to days. If one is lucky enough, promptly arranging a vascular team prepared to deal with the possibility of an aortic injury may be life saving.
- In the case presentation, the history of wheezing and coughing may have been due to the presence of the esophageal coin, or it may have been due to recurrent viral infections or an occult pneumonia refractory to amoxicillin. The presence of hemoptysis does not necessarily indicate tracheal injury since one could hemorrhage into the esophagus and have some of this blood mixed with expectorated mucus from an unrelated respiratory infection.
- Significant esophageal edema at the site of the foreign body may begin to occur within 48 hours of impaction. Thus, whenever an esophageal foreign body of uncertain duration is seen on the AP view, one should generally obtain a lateral view to look for a widening of the tracheoesophageal interspace which would be an indirect sign of significant esophageal edema.
- Whenever there is any suspicion of significant esophageal edema, the foreign body should be removed under controlled conditions via endoscopy and not blindly removed via the Foley catheter method.
1. Sloop RD, Thompson JC. Aorto-esophageal fistula: Report of a case and review of literature. Gastroenterology 1967, 53(5):768-777.
2. Tectmeyer CJ, McLean WC. Vascular injury following foreign body perforation of the esophagus. Ann Otol Rhinol Laryngol 1990;99:698-702.
3. Vella EE, Booth PF. Foreign body in the Oesophagus. Br Med J 1965;2:1042.
4. Turner GG. Death from perforation of the aorta by a halfpenny impacted in the oesophagus. Lancet 1910;1:1335-1336.
5. Lovett T. Ulceration into aorta due to foreign body in the oesophagus: Fatal hemorrhage. Br Med J 1909;1:1064.
Footnote: This case described is not an actual case. However, such cases have occurred in many centers with a similar course of events. The purpose of describing this sequence of events as a hypothetical case is to alert one to this possible pitfall.