Yasmine Roden, Charandeep Singh, Dabir Shah, Waseem Swati, Athar Sheikh, Peter Murchan
Background: Iatrogenic injury accounts for the vast majority of esophageal perforation (OP), an infrequently encountered complication of diagnostic endoscopy, but the risk of occurrence rising linearly with the increasing complexity of esophageal intervention. Outcomes correlate directly with extent of comorbidity variables, but also with the size and location of the perforation. Duration of time from OP to actual diagnosis has also been shown to be a critical factor in determining eventual outcome. We present a case of OP following a ‘simple’ biopsy of a Schatzki ring on diagnostic endoscopy, and outline lessons learned from its management.
Methods: A 48-year-old male underwent oesophagogastroduodenoscopy to investigate a 6-month history of dysphagia. He was previously treated for gastro-oesophageal reflux disease. The sole anomaly noted was a minimal ‘Schatzki’ ring at 35 cm, biopsied at 3 points. Within 1 hour, he developed acute severe chest pain and was tachypnoeic with saturations below 90% oxygen. Immediate chest X-ray and computed tomography scan revealed pneumomediastinum. Water-soluble contrast swallow demonstrated a para-oesophageal extravasation confirming the diagnosis of distal OP, within 2 hours from procedure.
Results: Aggressive medical management with high dependency unit admission, multi-disciplinary care, intravenous antibiotics and fluid therapy, patient controlled analgesia, and ultimately an interval delayed pleural and pericardial radiological drainage of fluid. Patient had protracted hospital stay of 32 days, following which repeat contrast swallow confirmed successful healing.
Conclusions: Early diagnosis of OP allows a planned management approach to the problem which is key in minimizing the inevitable cascade of sepsis events which can otherwise occur.
