Hook as foreign body: not all foreign bodies can be removed from the esophagus with endoscopy alone


Esophageal foreign bodies (EFBs) represent a relatively common and urgent clinical condition affecting all ages, which can lead to morbidity and mortality [1,2]. A retrospective study of 310 EFB patients demonstrated that the most commonly ingested foreign bodies in adults were bowls of meat and fish bones. [3]. It is much less common to find a hook as an EFB. Sharp foreign bodies (FB) pose a significant risk regardless of size due to their ability to puncture and cause other complications [4]. We present the unusual case of a 75-year-old patient who initially presented with acute neck pain after consuming fish. The neck x-ray revealed a FB hook in the cervical esophagus, requiring direct laryngoscopy and rigid esophagoscopy for removal of the FB. This case highlights the importance of proper food preparation and chewing well before swallowing. Additionally, urgent management of FB ingestion in adults is crucial for good outcomes without complications.

A 75-year-old man with a medical history of stroke three years ago, hypertension, hyperlipidemia, hypothyroidism, and gastroesophageal reflux disease presented to our hospital with neck pain. The patient did not report any known FB ingestion. He said his son caught a fish in the lake with his personal fishing gear. After eating the fish, the patient immediately felt pain in his neck and presented to the hospital soon after. He described the pain as non-radiating, moderate in intensity, and made worse by swallowing and coughing. At initial presentation, the patient was found to be hemodynamically stable and without acute distress. Soft tissue radiographs of the neck revealed an FB hook in the cervical esophagus approximately at the level of the cricopharyngeus (Figure 1).

Gastroenterology assessed the patient, reviewed laboratory and imaging findings, and recommended that the FB object was not amenable to endoscopic intervention with esophagoscopy due to its location at the upper esophageal sphincter in the hypopharynx, requiring better visualization with ENT instruments with airway protection. An otolaryngologist was consulted and within 24 hours direct laryngoscopy and rigid esophagoscopy were successfully performed resulting in symptom resolution without complications. A rough description of the specimen was provided by Pathology confirming it to be a metal steel hook measuring 1.7cm long and less than 0.1cm in diameter with a 4 inch white plastic string attached .0 cm long and less than 0.1 cm in diameter without tissue attached (Figure 2). A gastrografin study was subsequently performed to exclude perforation of the esophagus, which showed a normal gastrografin examination of the esophagus (Figure 3). The patient recovered uneventfully and was discharged.

FB ingestion commonly occurs in children and high-risk adult groups, such as those with underlying esophageal disease, acute intoxication, or severe psychiatric disorders [5]. The estimated incidence rate of FB ingestion is 13 per 100,000 people and accounts for approximately 1,500 deaths per year in the United States alone [1]. In adults, the esophagus is about 20 to 25 cm long and extends from the hypopharynx to the stomach. [6]. FB impaction is most likely to occur in the following sites: upper esophagus followed by middle esophagus, stomach, pharynx, lower esophagus and duodenum [2]. Additionally, FBs were more frequently lodged in the narrowest part of the upper esophagus at the level of the cricopharyngeal muscle, particularly in patients presenting to hospital within 24 hours of ingestion. [7]. Patients typically present to hospital with symptoms of odynophagia, dysphagia, FB sensation, chest pain, or nausea and vomiting [6].

The most common FB ingested in children are coins, button batteries and toys, while in adults it is usually food bowls, fish bones or chicken bones. [5]. These objects generally result from social activities; in contrast, fish hooks are unusual ingest items [8]. There are very few cases of hook like EFB reported in the last 20 years [8-11].

The majority of ingested FB passes spontaneously through the gastrointestinal tract, with 10-20% requiring endoscopic ablation and [12]. Endoscopic management is the first choice in the treatment of EFBs because it is safe, effective, cost-effective and avoids the need for surgery [13]. Moreover, a retrospective analysis of 188 cases of patients hospitalized with EFB between 1996 and 2006 revealed that the majority of FB cases were removed by rigid esophagoscopy, with only five cases of FB removed by surgery. [14]. During endoscopic extraction of sharp and pointed FB, the European Society for Gastrointestinal Endoscopy (ESGE) strongly recommends the use of a protective device to prevent esophagogastric/pharyngeal injury and aspiration [12]. The use of an overtube or a condom-type retractable latex rubber hood is effective in protecting the upper aerodigestive structures and facilitating endoscopy (Figure 4) [15]. Sharp, pointed, and elongated FBs, such as fishbones, are associated with an increased risk of perforation, vascular penetration, or other complications because they are more likely to be embedded in the esophagus [4]. Additionally, this risk is likely increased with a hook as an FB object due to the anatomy of a hook with its tip and barb(s), which can pose a challenge to remove (Figure 5). The backward projecting barb near the tip of the hook usually prevents removal of the hook, designed to lodge deep in a fish’s flesh and not intended for human ingestion [11]. In our patient’s case, the retrieved hook had a sharp point and multiple barbs.

Recent advances aimed at early diagnosis and elimination of FB may improve survival rates in these patients. Prompt treatment can yield good results, as we saw in the case of our patient. However, there are serious potential complications of FB ingestion if treatment is delayed, including mediastinitis, paraesophageal abscess, pneumomediastinum, subcutaneous emphysema, pneumothorax, tracheoesophageal fistula, fistula aortoesophageal, aspiration and asphyxia. [4]. Complications and length of hospital stay may be reduced if treatment is initiated within 24 hours of FB ingestion [7]. Some limitations to prompt treatment of FB may include social determinants of health such as access to care and transportation to hospital in underserved communities. A retrospective study found that longer duration of treatment, age above 60 years and impaction in the esophagus are some of the risk factors for developing complications after ingestion of FB [13].

FB ingestion is a common clinical problem in the United States, with meat boluses and chicken bones being identified as the most commonly encountered FB objects. The hook as FB is unusual and warrants extra care in management due to the increased risk of complications. Although endoscopic procedures have achieved a high success rate and efficiency in the management of EFBs, it is important to note that the use of a protective device when removing sharp FBs is recommended to avoid injury. gastroesophageal/pharyngeal and aspiration. In addition, food must be prepared appropriately and consumers must observe what they intend to swallow. Patients with FB ingestion should present themselves to the emergency hospital for appropriate management. Complications can be reduced if treatment is performed within 24 hours of FB ingestion.

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