Perforation of the oesophagus and aorta after eating fish: an unusual cause of chest pain

Abstract

Naltrexone is a long acting opioid receptor antagonist used in controlled opioid withdrawal drug programmes. When taken by an opioid dependent patient an acute withdrawal reaction will be precipitated. The case is presented where a known opioid drug misuser inadvertently ingested naltrexone in conjunction with heroin resulting in severe agitation, requiring heavy sedation followed by general anaesthesia to enable investigation and management of his clinical condition. N altrexone is a long acting opioid receptor antagonist used in drug rehabilitation programmes to maintain opioid abstinence. However, when consumed in conjunction with an opioid substance, prolonged opioid withdrawal will be precipitated resulting in unpredictable and life threatening medical consequences. We present a case where a known drug misuser consumed naltrexone in conjunction with heroin. CASE REPORTA 39 year old man presented to the accident and emergency department having taken up to three, 50 mg tablets of naltrexone and having smoked an unknown quantity of heroin. He was known to be an injecting drug user and to suffer from epilepsy. No other recreational drugs, alcohol, or prescribed medications were known to have been consumed. On arrival he was extremely agitated being restrained by four police officers. He was confused, sweating, with episodes of profuse projectile diarrhoea and vomiting. Glasgow Coma Scale was 12 (spontaneous eye opening, localising to pain, and using inappropriate speech). Pupils were dilated but reactive to light. Heart rate was regular at 180 beats/minute and respiratory rate 40 breaths/minute. Blood pressure, oxygen saturation, blood glucose, and temperature were normal. There was no evidence of head injury and no history of seizure. Urea, electrolytes, full blood count, and arterial blood gas measurements were normal. Initial attempts at sedation using a combination of titrated intravenous midazolam and droperidol were unsuccessful. After receiving a total of 20 mg midazolam and 15 mg droperidol he continued to be confused, agitated, and increasingly violent. An urgent CT head scan was arranged to exclude any intracranial pathology. To expedite this he was anaesthetised and ventilated. Rapid sequence induction of anaesthesia was carried out using 200 mg propofol, and 100 mg suxamethonium. Anaesthesia was maintained with a propofol infusion and incremental paralysis with atracurium.CT of his brain was normal. A lumbar puncture was performed while the patient was still anaesthetised. This showed no abnormality. The patient was extubated four hours after induction and transferred to the medical high dependency unit for observation. Further episodes of agitation occurred overnight requiring additional sedation with intravenous midazolam. The following morning he took his own discharge. Retrospectively urine toxicology screen confirmed the presence of cannabinoids, benzodiazepines, and opioids.

Esophageal Large Fish Bone (Sea Bream Jawbone) Impaction Successfully Managed with Endoscopy and Safely Excreted Through the Intestinal Tract

“…Foreign bodies most commonly perforate the cervical esophagus (7). The second most common site for perforation is at the level of the aortic arch (7,8) where there is scope for fatal or life threatening vascular and respiratory catastrophe. An esophageal perforation or penetration due to fish bones may lead to severe clinical problems such as bleeding (9,10), pseudoaneurysm (11), mediastinitis (12), mediastinal abscess (13) or other diseases (14)(15)(16)(17).…”

“…An esophageal perforation or penetration due to fish bones may lead to severe clinical problems such as bleeding (9,10), pseudoaneurysm (11), mediastinitis (12), mediastinal abscess (13) or other diseases (14)(15)(16)(17). Aortooesophageal fistula due to fish bone is often resulting in mortality (18,19) and it should be managed surgically (20). Thus, impacted fish bone in the esophageal wall should be removed as soon as possible (21).…”

Fish hook and line impaction in the Esophagus: An unusual and interesting foreign body

“…The Otolaryngologist needs to deal with sharp aero-digestive foreign bodies fast so as to avoid deeper tissue penetration and subsequent abscess formation as reported by Afolabi et al [2] and D'Costa et al [5].…”

Aortoesophageal perforation following ingestion of razorblades with massive haemothorax

“…Causes described include aortic aneurysms, locally advancing malignancy, foreign body ingestion and trauma including iatrogenic causes [3]. In over 2000 case reviews of foreign body ingestion, only 25 cases (1%) resulted in oesophageal perforation typically involving fish or chicken bones, of which two cases developed an aortoesophageal fistula [4].…”