گزارش يك مورد پارگي مري در اثر بلع جسم شيشه اي

Esophageal Perforation due to Swallowing a Glass Body

پارگي مري حالتي نادر اما بسيار جدي و مهم است كه به طور معمول نياز به ترميم جراحي دارد. پارگي مري مي تواند بسيار خطرناك و حتي تهديد كننده ي حيات فرد باشد، از اين رو نيازمند به مداخله ي فوري جراحي است. درد اولين علامتي است كه ظاهر مي شود. پارگي در يك سوم مياني و تحتاني مري احتمالاً باعث مشكلات بلع، مشكل در تنفس و درد قفسه ي سينه مي شود. آقاي 61 ساله اي به علت احساس جسم خارجي و درد اپيگاستر به دنبال بلع غذا به اورژانس مراجعه مي كند و تحت اندوسكوپي فوقاني قرار مي گيرد. جسم خارجي در يك سوم تحتاني مري مشاهده مي شود. باتوجه به فرو رفتن جسم خارجي نوك تيز در دو سمت ديواره مري، بدون تلاش براي خروج جسم خارجي، بيمار سي تي اسكن بدون كنتراست شد كه در آن هوا در Right Posterolateral Mediastinum و پلورال افيوژن مختصر در همي توراكس راست ديده شد. بيمار به علت سابقه ي قلبي قابل توجه، به توصيه ي جراح توراكس جراحي نشده اما جسم خارجي در اتاق عمل (تحت شرايط آمادگي براي تبديل فرآيند به توراكوتومي) به وسيله ي پروب اندوسكوپي بيرون آورده مي شود. به دنبال اين عمل، در سي تي اسكن توراكس با كنتراست خوراكي بيمار، هواي آزاد و نشت ماده ي حاجب در Right Posterolateral Hemithorax و افزايش پلورال افيوژن مشاهده شد و بلافاصله تزريق نرمال سالين در دو طرف محل پارگي مري با اندوسكوپي انجام شد تا از نشت بيشتر جلوگيري شود. بيمار يك هفته تحت نظر سرويس جراحي و گوارش قرار گرفت تا درصورت مدياستينيت، توراكوتومي شود. پس از يك هفته بيمار مورد بلع گاستروگرافين و سپس بلع باريوم قرار گرفت كه با توجه به نبود شواهد مبني بر بقاي پارگي و يا ميكروپرفوراسيون، بيمار مرخص شد.

Esophageal perforation is a rare yet very serious condition, which usually needs surgical repair. In spite of its rarity, esophageal perforation could become extremely dangerous and even life-threatening. Therefore it needs immediate surgical intervention. The first symptom to appear is pain. Perforation in the middle and lower third of the esophagus might as well cause difficulty in swallowing, dyspnea, and chest pain. A 61-year-old man presented to the Emergency Room due to sensation of a foreign body and epigastric pain after meal for which he underwent upper endoscopy. The foreign body was seen in the lower third of the esophagus. Considering the bilateral penetration of the sharp foreign body to the esophageal wall, no effort was made to bring the foreign body out. The patient underwent computed tomography (CT) without contrast, which showed right posterolateral mediastinal air leakage and slight pleural effusion in the right hemithorax. As recommended by thoracic surgeon, instead of thoracotomy, the foreign body was brought out in the operating room by endoscopy (under preparation in order to convert the procedure to thoracotomy if needed). After the procedure, a CT with oral contrast was done, which showed free air and leakage of contrast to the right posterolateral hemithorax as well as an increase in the pleural effusion. Normal saline was immediately injected to both sides of the perforation site by endoscopy in order to prevent further leakage. The patient was observed by both surgery and gastroenterology teams for a week to undergo thoracotomy in case he develops mediastinitis. After a week, he underwent Gastrografin swallow and then Barium swallow. The patient was discharged from the hospital because no evidence of remaining perforation or any microperforations were seen. Esophageal perforation is a surgical emergency usually happening due to diagnostic and pass through esophagous to go to the therapeutic actions. Most swallowed foreign bodies stomach, but sharp objects may cause perforation in esophagus. Foreign bodies mostly get trapped in the physiologic constrictions. Dysphagia and odynophagia are subcutanneous common symptoms of foreign body invasion in to the esophagous. Emphysema is a diagnostic key for the matter of esophageal perforation. Treatment for such condition differs among various patients.