Esophageal Perforation: Can We Hold the Tray and Spare the Knife?

1Cleveland Clinic, Cleveland, OH

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 236

Case Presentation:

A 38‐year‐old African American man with a medical history of hiradenitis suppurativa (HS) presented with 1‐year history of left leg ulcer with a 2‐week increase in size and malodorous discharge. He denied any obvious bleeding or anemia symptoms other than mild fatigue. Examination revealed features of HS with bacterial superinfection. Labs revealed microcytic anemia consistent with iron deficiency with hemoglobin 6.1, MCV 70, ferritin 46, and transferrin saturation of 5. Esophagogastroduode‐noscopy (EGD) was done for anemia evaluation, and there was endoscopist‐documented difficulty in entering the esophageal orifice and a possible diverticulum, but the findings were otherwise normal. On return from EGD suite, he complained of a sensation of having “something left behind” after the procedure, with pain in the throat and back. Physical examination was negative for tachycardia, tachypnea, or a mediastinal crunch (Hamman's sign). Chest x‐ray revealed pneumomediastinum and subcutaneous emphysema on both sides of neck. A gastrograffin esophago‐gram was negative for any leak. Thoracic surgery was consulted, and the patient was managed conservatively with nothing by mouth (NPO) and antibiotics. After 3 days, the patient's neck pain improved, and repeat imaging showed improvement in the pneumomediastinum. He was started on a clear liquid diet and advanced to a regular diet without any further complications.

Discussion:

EGD is a very common procedure done in the hospital. Although relatively safe, it still has a risk of esophageal perforation of 0.03% for diagnostic purposes and much higher risk when used for therapeutic interventions like dilation. The presentation, diagnosis, and outcomes differ depending on the site of perforation (Table 1). Plain x‐rays and contrast esophagography generally establish the diagnosis, but false‐negative results occur in 10% of patients, especially in the upright position. CT scan increases the sensitivity for diagnosis. Esophageal perforation is a surgical emergency, as a delay in diagnosis and treatment by a mere day can decrease the survival to less than 50%. Nonsurgical management is described in a few select patients provided the perforation is contained with no leak on esophagogram, no evidence of extension into pleura or peritoneum, no preexisting esophageal lesions, no evidence of sepsis or hemodynamic instability, and the patient can be monitored carefully with minimal pain. These patients are kept NPO, treated with broad‐spectrum antibiotics like a beta‐lactam/lactamase combination, and often need parenteral nutrition depending on duration of NPO. Small perforations can often be treated endoscopically with stents or clipping with good results.

TABLE 1 Features of Esophageal Perforation

Pneumomediastinum.

Conclusions:

Our patient illustrates that although esophageal perforation is a surgical emergency associated with significant mortality, nonoperative management may still be an option for select patients.

Disclosures:

R. Bahuva ‐ none; A. Mehrotra ‐ none; A. Satra ‐ none; P. Khanna ‐ none

To cite this abstract:

Bahuva R, Mehrotra A, Satra A, Khanna P. Esophageal Perforation: Can We Hold the Tray and Spare the Knife?. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 236. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/esophageal-perforation-can-we-hold-the-tray-and-spare-the-knife/. Accessed November 19, 2019.

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