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Dysphagia Due to Blister Pack Pill in Elderly : A Rare Entity
Arshad S Khan*, Girish D Bakhshi**, Bhushan A Thakur***,
Parminder S Sourot+, Chetan K Merchant+, Nikhil S Agarkhedkar+
Abstract
Dysphagia is a Greek word that means disordered eating. Dysphagia typically refers to difficulty in eating as a result of disruption in the swallowing process. Dysphagia can be a serious threat to one’s health because of the risk of aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. Dysphagia has many causes, including mechanical obstruction and neurologic disorders. Foreign bodies occasionally cause dysphagia, especially in the elderly and in children.1 We present a case of 70 year old female who presented with an unusual cause of dysphagia.
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Introduction
Foreign body (FB) impaction of the upper
digestive tract is a common problem in both children and adults. The estimated annual incidence of foreign body ingestion in the United States is about 120 per million population, with approximately 1500 deaths each year.2 Typically, two types of FBs are encountered—true FB (e.g., coins, buttons) and food-related FB. The three common areas for oesophageal FB impaction are just below the cricopharyngeal muscle (70%), the site where the aortic arch crosses the anteromedial wall of the oesophagus (20%), and at the gastro-oesophageal junction (10%). In most cases, an impacted oesophageal FB is an urgent medical situation, but not a life-threatening one.3 We present a case of 70 year old lady, who presented to us with dysphagia due to unusual foreign body.
Case Report
We present a case of a 70 year old lady, who presented to us with dysphagia and retrosternal pain since 3 months. Onset was sudden and remained the same. Patient had past history of ischaemic heart disease with hypertension. She was on oral antihypertensive drugs. Clinical examination was unremarkable. Her cardiac work up ruled out cardiac ischaemia. Barium swallow showed a filling defect in mid-oesophagus. Patient was called for endoscopy. Her upper G.I. endoscopy revealed a pill still wrapped in its plastic blister pack lodged in the mid-oesophagus (Fig.1) causing an ulcer at the site of impaction. The blister pack intact along with the pill was removed with the help of biopsy grasping forceps. Endoscopy also showed gastritis. Once pill was removed patient was given proton pump blockers. Patient as well as her relatives were also educated regarding taking her medication. Patient was relieved of her symptoms. Repeat endoscopy done after 3 weeks showed healed ulcer in the oesophagus. Post-operative follow-up of 6 months has shown her to be symptom free.
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Discussion
Foreign body ingestion is one of the most common problem in children and adults. Most of the ingested foreign bodies are of food origin that are most commonly impacted in the oropharynx followed by the oesophagus. Oesophageal obstruction by a foreign body is most likely to occur at anatomoic narrowings: the post cricoid area, aortic arch, left main bronchus and diaphragm.2 Since the advent of fibreoptic endoscopy, a wide variety of ingested foreign bodies have been successfully removed from the upper Gastrointestinal tract (GIT). Adults who intentionally ingest foreign bodies frequently have psychiatric disorders, mental retardation, alcoholism or are prisoners seeking the secondary gain associated with hospitalization. Adults who accidentally ingest foreign bodies are predisposed by carelessness, rapid eating, poor eyesight, alcohol intoxication or use of dentures with resultant lack of sensation of the hard palate.4 Our patient was an old lady who accidentally took pill wrapped in its blister pack.
The patient usually complains of sudden onset of pain or discomfort in the throat or chest after swallowing some tablets, inability to finish the meal, progressive or worsening symptoms, severe pain at rest and dysphagia. Our patient presented with dysphagia and retrosternal pain. Clinical examination includes visualisation of the pharynx/hypopharynx by indirect laryngoscopy or flexible nasopharyngoscopy. However, in oesophageal foreign body impaction upper G.I.T. endoscopy is diagnostic as well as therapeutic. Lateral neck X-rays have been useful in fish bone impactions and particularly in cervical oesophageal foreign bodies.4 Barium swallows or CT scans are used where thoracic oesophageal foreign bodies are suspected. In our case plain X-ray was unremarkable whereas, barium swallow showed a filling defect suggestive of polyp or growth.
The most popular technique for the removal of impacted oesophageal FB is rigid oesophagoscopy. Others include flexible fiberoptic oesophagoscopy, Foley catheter technique, and oesophageal bougienage.5,6,7 Flexible fiberoptic oesophagoscopy has been found to have the same advantages as the rigid technique.8 Objects that have been impacted for more than a few hours, such as sharp objects, buttons, batteries and objects that are not smooth or inert, can be removed safely by flexible endoscope.8,9 However, the procedure is costly and must be performed by a skilled endoscopist. In selected cases, FB removal may be accomplished using a balloontipped catheter. Contraindications to this procedure include acute distress, complete obstruction, impaction for more than 24 hours, unknown FB, known oesophageal disease and impaction of objects that are not inert or smooth.9
The technique of pushing the FB into the stomach with a bougie has also been advocated.10 Those advocating balloon catheter or bougienage technique cite the following advantages over oesophagoscopy: avoidance of hospitalization, avoidance of the risks of general anaesthesia and endotracheal intubation, and avoidance of the risks of oesophagoscopy.11 In our case, flexible endoscopy was done under local spray anaesthesia and blister pack was removed with the help of biopsy grasping forceps.
The ingestion of blister packs is a rare problem.12 Diagnosis of this condition requires an index of suspicion. Press through blister packaging for pills is being increasingly used by drug companies as a safe and hygienic method of storage and dispensation of medication. Such packs not only protect the tablet from the effects of moisture and light, but also allow quick and easy counting for dispensing purposes. An interesting benefit reported is the reduction in the number of pills swallowed in drug overdose cases, probably related to the extra effort required to remove such packaging compared to pouring loose pills direct from a bottle.13 With more tablets being packed in blister packs, the issue of medication in the elderly should be addressed by the attending doctor as elderly patients are commonly on polypharmacy due to ill health. Moreover, failing vision and use of dentures reduce the ability of the teeth and palate to feel for foreign bodies.4
Blister pack ingestion, though rare in incidence, is expected to increase with increasing use of such packaging and also with the rising elderly population in our country. Preventive measures suggested include use of air-tight pill boxes for pill storage12 and education to the patient as well as their relatives to avoid cutting blister packs into ingestable squares. Manufacturers can help by making packages harder and more difficult to cut.12 Pill packaging should come with prominent warning labels advising against cutting up blister packs.
To summarize, prevention is better than cure, however, blister pack ingestion should be kept as a differential diagnosis in elderly patients presenting with dysphagia.
Acknowledgement
We would like to thank Dean, and Dr. B.M.Subnis Head of the Department of Surgery, Grant Medical College and Sir J.J.Group of Hospitals for granting us permission to publish this case report.
References
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