A kiss from the bread: Esophageal ulcer induced by bread impaction in an adult male

A 52-year-old male, a property broker known for his fast-paced lifestyle, presented with a history of severe chest discomfort immediately after consuming a large slice of bread (Figure 1) in his rush to get to work. He exhibited a type A personality, had no comorbidities, and did not take any regular medications. Since then, he has experienced ongoing chest pain accompanied by a sensation of the bread being lodged in his chest. Six hours later, his incarcerated sensation started to decrease after massive water and milk consumption. However, the chest pain still persisted. His gastroduodenoscopy showed a 3.5-cm ulcer in the middle esophagus (Figure 2). His chest symptoms gradually improved after a week treatment with sucralfate 1 g four times daily. The decision to use sucralfate instead of proton pump inhibitors was based on its direct action on the ulcer, forming a protective film that could prevent further deterioration of the esophageal ulcer. A compression ulcer produced by incarcerated bread might occur, possibly due to compression-related ischemia of the mucosa. A bread-related esophageal ulcer tends to occur at middle esophagus, the anatomical narrowing site behind left atrium. Esophageal ulcers can arise from various factors, including reflux esophagitis, viral infections, or medication use.1-3 In this case, the mechanical obstruction caused by the bread likely contributed to the development of the ulcer given the sequence of events. In the literature, there have been reports of fatality and laceration caused by bread crust and bagel, respectively.4, 5 The autopsy of the former case revealed perforation at the upper end of the esophagus with a mediastinal abscess.4 In the latter case, a barium-swallow exam indicated a 4-cm mucosal tear extending from the upper esophagus to the cricopharyngeal muscle.5 However, the patient survived with conservative medical treatment involving narcotic analgesics, antacids, and intravenous hydration. All authors contributed equally to the review of data, drafting of manuscript, and approval of final version. The study was funded by research foundation of An Nan Hospital (grant numbers: ANHRF112-09 and ANHRF112-45), China Medical University, Taiwan and Ping Tung Christian Hospital Research Fund (grant number: PS 113005). The authors declare no conflicts of interest. Informed consent was taken from patient for clinical image submission.