Placement of covered self-expanding metal stent to treat razor blade-induced esophageal hemorrhage

Table of Contents

A prisoner (42 years old) was admitted to a hospital emergency department after swallowing razor blades in a suicide attempt. The patient had no symptoms such as retrosternal pain or dysphagia. The blades were extracted endoscopically, which caused longitudinal esophageal lesions and acute bleeding. The insertion of a Sengstaken-Blakemore tube initially stabilized the patient. After the tube had been deflated, massive hematemesis with hypovolemic shock required the insertion of a self-expanding metal stent (SEMS) (SX-Ella DANIS Stent; ELLA-CS Co., Hradec Kralove, Czech Republic) ([Fig. 1]).

Fig. 1 The SX-Ella DANIS stent, which is atraumatic, stopped esophageal bleeding following razor blade ingestion: a Inflation of the balloon below the lower esophageal sphincter allows correct positioning of the stent. b Completely self-expanded metal stent.

During hospital treatment, the patient developed a bilateral pulmonary embolism that needed high intensity anticoagulation. The patient then suffered again from severe hematemesis. Massive transfusion (hemoglobin 5 mg/dl), orotracheal intubation, and cardiopulmonary resuscitation was necessary. Upper gastrointestinal endoscopy showed pulsatile arterial bleeding. Computed tomography (CT) angiography revealed an aortoesophageal fistula, probably also of traumatic origin as a consequence of the razor blade extraction ([Fig. 2]).

Fig. 2 Computed tomography (CT) scan of the aortoesophageal fistula due to a thoracic aorta pseudoanuerysm located 1 cm distal to the subclavian artery on the descending thoracic aorta. The neck of the fistula starts at the level of the aortic arch.

An endoluminal stent graft (Zenith Endovascular Graft; Cook Ltd., Limerick, Ireland) was implanted in the aorta via the left femoral artery ([Fig. 3]).

Fig. 3 Computed tomography (CT) scan showed the endoluminal and endovascular stent grafts to be in the correct positions, with no important leakage.

The patient recovered well; even under high-intensity anticoagulation, the patient experienced no bleeding when the stent was extracted.

The ingestion of foreign bodies is frequently seen in pediatric or psychiatric patients, and can cause severe morbidity and mortality. Endoscopy is an important diagnostic and therapeutic tool, although foreign bodies usually pass spontaneously [1] [2]. Even ingestion of potentially harmful objects such as razor blades seldom leads to severe complications [3]. New stent devices offer a safe and effective treatment option for acute and refractory variceal bleeding [4] [5] and severe injuries of the gastrointestinal tract [6]. An aortoesophageal fistula is a rare complication of swallowing a foreign body, typically fish or chicken bones [7].

In our patient the esophageal bleeding was stopped effectively using an atraumatic membrane-covered SEMS. The aortoesophageal fistula that was secondary to the treatment was treated by endovascular stent grafting. Both techniques may be an alternative to surgical intervention. These results for esophageal bleeding have to be confirmed by randomized controlled trials with a large number of patients.

Competing interests: None

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