Case history
Case history #1
A 33-year-old male surgical resident presents to the emergency department after lunch complaining of dysphagia for solids and liquids. The patient has no previous history of upper gastrointestinal disease and has suffered from only mild solid food dysphagia over the past few years. All previous dysphagic episodes underwent spontaneous resolution and some of them were occasionally associated with various atopic symptoms.
Case history #2
An 11-month-old girl is brought to the hospital with a 2-week history of worsening respiratory symptoms, vomiting, fever, poor appetite, and weight loss. Her mother describes several episodes of nonprojectile, nonbloody, nonbilious emesis during feeding. Prior to these 2 weeks, the patient was well. X-ray abdomen reveals a round metallic foreign body obstructing the cervical esophagus, which is found to be a coin.
Other presentations
Delayed and unusual presentations are seen most commonly in young children and patients with an intellectual disability. These patients may have limited communication skills and present with an imprecise history. There may be no clear evidence of swallowing an object or device, or they may exhibit an atypical presentation, such as poor appetite, irritability, failure to thrive, fever, wheezing, stridor, pulmonary symptoms, or recurrent pneumonias from aspiration. These symptoms may indicate an impacted foreign body in the hypopharynx, upper esophagus, or respiratory tract. In cases where a foreign body has passed into the stomach or small intestine, patients tend to be asymptomatic or report only mild symptoms; these may include nausea, nonbilious vomiting, and/or persistent or intermittent abdominal pain that may develop minutes, hours, or weeks after swallowing the foreign body (depending on the exact nature of the object). Foreign body ingestions in these populations represent some of the most challenging clinical scenarios facing a gastroenterologist.[1][2][3]
Some groups of patients (e.g., prisoners, patients with psychiatric pathologies, and patients who have an intellectual disability) may not volunteer a history of foreign body ingestion. This group of patients may swallow a wide variety of objects either to hide these from the authorities or to seek medical care. The incidents often involve ingestion of small metal objects (e.g., paper clips, razor blades, screws, nails, pens, eating utensils). Their presentation may vary from asymptomatic to fever, abdominal pain, vomiting, or a surgical emergency.[4]
Body packers typically smuggle drugs (usually highly concentrated cocaine or heroin) in a silicone packet or sac (e.g., a condom), which may be swallowed, placed in the rectum, or surgically implanted in the body. This can lead to lethal medical complications. They may present with severe abdominal pain or with an acute drug toxicity from a ruptured packet.[5]
Patients with a history of esophageal prostheses, such as a self-expandable plastic or metal stent, may present with upper gastrointestinal symptoms. Historically, these esophageal prostheses were used primarily as palliative treatment of unresectable esophageal cancer. However, the indications for use of esophageal stents have expanded and include secondary strictures, fistulas (e.g., tracheoesophageal or post-bariatric surgery or postbariatric surgery), and leaks.[6][7][8]
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