A 60-year-old man with a past medical history significant for nonalcoholic steatohepatitis-induced cirrhosis and esophageal varices was evaluated by our gastroenterology service for possible liver transplantation. He was scheduled for esophagogastroduodenoscopy with the aim of possible band ligation of his varices. Owing to borderline hypotension, conscious sedation was achieved with 3 mg of intravenous midazolam. During the procedure, the patient became restless. He was able to push the bite block forward and bit the tip of the endoscope where the handle and ligator were positioned. The endoscope was withdrawn immediately and the plastic piece was noted to be missing. The endoscope was reinserted and a thorough examination of the upper gastrointestinal tract was performed to the level of the duodenum without visualization of the foreign body. At this point it was assumed the patient had aspirated it, and the pulmonary service was consulted for bronchoscopy. On physical examination, the patient was not in respiratory distress with stable vital signs. Lung examination demonstrated minimal right-sided expiratory wheezing with no other abnormalities. A chest x-ray performed immediately showed no evidence of a foreign body, infiltrates, or atelectasis. A chest computed tomography was obtained, which revealed the plastic piece had lodged in the right mainstem bronchus, as would an endobronchial stent, without any large airway obstruction (Fig. 1). The patient was taken for bronchoscopy under deep sedation. He was intubated with an 8 mm endotracheal tube. A therapeutic Pentax flexible bronchoscope was introduced through the endobronchial tube. The plastic piece was immediately visualized in the right mainstem bronchus (Fig. 2). Rat-tooth grasping forceps were used to grasp the foreign body. The endotracheal tube, bronchoscope, and foreign object were removed simultaneously through the vocal cords without complication (Fig. 3). The endotracheal tube was reinserted and a complete airway examination was performed and was found to be normal. The patient was successfully extubated and was admitted for observation. He was discharged to home the next day.
Foreign body aspiration occurs infrequently in adults.1 The swallowing reflex is usually protective against foreign body aspiration into the airways.2 In adults, aspiration of foreign bodies are most commonly seen after the sixth decade and are often associated with alcohol ingestion, sedative abuse, traumatic intubations, neurologic disorders, or dental procedures.1,3
Medications commonly used for conscious sedation during a wide variety of procedures can impair the swallow and cough reflexes. Patients undergoing oropharyngeal procedures such as esophagogastroduodenoscopy are at risk for foreign body aspiration from medical equipment.
Regardless of the setting, two-thirds of aspirated objects lodge in the mainstem bronchi rather than in more distal airways.4 Flexible bronchoscopy is generally required for confirmation of transbronchial foreign body aspiration.5 In cases in which a firm grip is necessary to prevent a hard foreign body from slipping (as in this example), alligator jaws, rat-tooth, or shark-tooth forceps are recommended.6 Bronchoscopic foreign body removal carries a remote risk of bleeding and pneumothorax.1 The removal of a foreign body from the airway generally leads to rapid resolution of respiratory symptoms.7
Because of the absence of specific respiratory symptoms, adult airway foreign body aspiration is often misdiagnosed.8 Proximal airway obstruction and acute life-threatening asphyxia is the most important complication of foreign body aspiration. Pneumonia is a common late complication.9 This is first case report of foreign body aspiration during an endoscopic band ligation and should be taken into consideration by clinicians especially if there is new onset of respiratory symptoms or a missing part of equipment is identified. Definitive treatment is removal of the foreign body as soon as possible.
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