SESSION TITLE: Critical Care Case Report Posters II
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: We present a case of a patient with esophageal perforation in the setting of esophageal necrosis, a rare entity in which the association is not commonly reported.
CASE PRESENTATION: A 73-year - old male was brought to an outside hospital with complaint of syncope followed by PEA arrest. He was intubated and was found to have a right sided hydropneumothorax .He was started on empiric antibiotic therapy along with vasopressor support for septic shock. He was transferred to our institution’s medical intensive care unit. On examination, he was unresponsive to painful stimuli. He had bilateral coarse breath sounds. There was a right-sided chest tube draining dark material. The pleural fluid was exudative with amylase level of 795 U/L. Imaging showed a right pneumothorax with associated pneumomediastinum and pneumopericardium and bilateral pleural effusion (Figure1). The patient was treated with vasopressor support and antimicrobials. Emergent esophagogastroduodenoscopy was done to rule out esophageal perforation. It revealed ischemic esophageal mucosa with perforation defect in the esophagus with clear visualization of the right chest through it and a healthy stomach. Patient had esophagectomy. He tolerated the procedure but remained critically ill. The surrogate decision maker subsequently requested comfort measures only.
DISCUSSION: Esophageal perforation can be fatal if not promptly diagnosed. Most cases are iatrogenic but other etiologies include Boerhaave’s syndrome, foreign body ingestion, trauma and malignancy. Acute esophageal necrosis (AEN) first described by Goldberg et al in 1990, is a rare entity that is not frequently associated with esophageal perforation. Endoscopically it is a circumferentially distributed dark lesion in the distal one-third of the esophagus. Necrosis involves the mucosal and submucosal layers of the esophagus and rarely transmural necrosis leading to perforation. The etiology of AEN is unknown but believed to be associated with a low-flow state. This patient likely developed a low flow state in his esophagus after syncope and shock resulting in acute esophageal necrosis and subsequent esophageal perforation.
CONCLUSIONS: We conclude that acute esophageal necrosis is a rare entity that can progress to esophageal perforation in a critically ill patient with impaired mucosal defense mechanisms. If not promptly treated, esophageal perforation can lead to death.
Reference #1: Tidman MK; John HT. Spontaneous rupture of the oesophagus. The British Journal Of Surgery [Br J Surg], 1967 ; 54 (4), 286-92
Reference #2: Goldenberg SP, Wain SL, Marignani P. Acute necrotizing esophagitis. Gastroenterology 1990; 96; 493-496
DISCLOSURE: The following authors have nothing to disclose: Lyndave Francis, Marvin Balaan, Omer Bajwa
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