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Recurrent Epigastric Pain in an 82-Year-Old Woman

Recurrent Epigastric Pain in an 82-Year-Old Woman

An 82-year-old woman who had recently
arrived from Japan presented to the
emergency department with a 3-day
history of abdominal pain that began
immediately after she swallowed several
pills with a small amount of water.
The severe, intermittent pain radiated
to the patient's back and worsened with
meals. The patient denied chills, nausea,
vomiting, coughing, diarrhea, and
constipation. She had well-controlled
type 2 diabetes mellitus and hypercholesterolemia,
and had undergone an
appendectomy 50 years earlier.

The patient was in moderate distress.
Her temperature was 38.3C
(101F); blood pressure, 116/44 mm
Hg; pulse rate, 88 beats per minute;
and respiration rate, 19 breaths per
minute. Epigastric and right upper
quadrant tenderness with no rebound
or guarding was noted; Murphy's sign
was negative. The white blood cell
(WBC) count was 18,500/μL, with
7% bands and 89% neutrophils. Liver
function test results and amylase and
lipase levels were normal; there was
no occult blood in the stool.

An ECG showed normal sinus
rhythm with no ischemic change; cardiac
enzyme levels were normal. An
abdominal ultrasound scan and a hepatic
2,6-dimethyliminodiacetic acid
scan were negative for gallbladder disease.
Chest and abdominal films were

The pain initially resolved after
the patient received a GI cocktail
(Donnatal, Mylanta, and Xylocaine);
she was given a proton pump inhibitor
and admitted to the hospital. On the
second hospital day, the pain returned
and atrial fibrillation was noted; abdominal
findings remained unchanged.
The patient was afebrile; her WBC
count was normal. A CT scan of the
abdomen revealed small bilateral
pleural effusions but no abdominal
pathology. The atrial fibrillation resolved

Figure 1
Figure 1
Figure 2
Figure 2

Two days later, the patient again
complained of epigastric pain and experienced
atrial fibrillation. Because
of her recent airplane trip, a spiral
CT scan of the thorax was obtained to
assess for pulmonary embolism. The
study demonstrated mediastinal air
posterior to the esophagus (Figure 1)
and a possible distal esophageal perforation,
which was confirmed by a
meglumine diatrizoate esophagram
that revealed extravasation of the contrast
confined to the mediastinum
(Figure 2).

Broad-spectrum intravenous antibiotics
were initiated. Total parenteral
nutrition and intravenous hydration
were started; nothing was given by

On hospital day 17, a follow-up
esophagram showed that the esophageal
perforation had resolved and a round
filling defect in the distal esophagus persisted,
which suggested the presence of
a foreign body (Figure 3). An esophagogastroduodenoscopy
revealed a pill
within a plastic casing lodged in the
esophageal mucosa at the site of the
perforation (Figure 4). The dime-size
wrapped pill was removed endoscopically
without complications. The patient
was able to tolerate a clear diet
and was discharged from the hospital 2
days later.

Figure 3
Figure 3
Figure 4
Figure 4


Instrumental injury accounts for
33% to 48% of all esophageal perforations1,2;
trauma or forceful vomiting
(Boerhaave syndrome, see CONSULTANT,
May 2001, page 831) and diseases
of the esophagus also can
cause perforation.

Esophageal perforation following
foreign body ingestion is rare3; children,
elderly persons with dentures,
prisoners, and psychiatric patients are
at greatest risk. Sharp- or roughedged
objects, such as bones, coins,
needles, toys, and batteries, can
pierce and perforate the esophagus
spontaneously or during their removal
by endoscopy.4,5 Impacted foreign
objects also can cause slow pressure
necrosis, weaken the mucosa,
and lead to perforation.

Pill-induced esophageal injury
resulting in perforation has been reported.
6,7 For our patient, 2 possible
modes of injury are likely: the sharp
object perforated the distal esophagus,
or the sharp foreign body partially
penetrated the mucosa and induced
a pressure necrosis that led to
perforation. A similar case of a pill becoming
a foreign body has been reported,
8 but we found no instances in
the literature of such an impaction
causing esophageal perforation.


The presenting symptoms of
esophageal perforations may differ
according to the perforation's location
(cervical, thoracic, or abdominal).
The classic triad-pain, fever, and the
astinal air-is associated with perforation
at all 3 sites.5 Patients with cervical
perforation commonly have subcutaneous
emphysema and chest
pain9; those with thoracic perforation,
such as this patient, often complain of
upper back and abdominal pain.10
Laboratory investigations may reveal
leukocytosis.11 Odynophagia and dysphagia
are frequent complaints when
a foreign object is present in the


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