AB151. SOH21AS111. Management of iatrogenic oesophageal perforation: a case report

Background: Sixty percent of oesophageal perforations are iatrogenic. Oesophageal perforation may cause mediastinitis and sepsis, with a 10–20% mortality rate. Prompt treatment improves survival. The Pittsburgh Perforation Severity Score (PSS) guides treatment and stratified patients into low (≤2), intermediate (3–5) and high risk (>5). Treatment is guided by the PSS score. Options include; conservative management, incorporating broad spectrum antimicrobial cover, feeding adjuncts and endoscopic interventions. For high risk cases, surgical debridement and repair may be undertaken, with emergency oesophagostomy reserved for severe cases. The aim of this report is to use a case study to discuss management strategies.

Methods: A 51-year-old male was transferred from another hospital, following a prolonged oesophagogastroduodenoscopy (OGD) for removal of a food bolus. The patient reported chest pain during the procedure and surgical emphysema was palpated in his neck. Computerized tomography revealed extensive subcutaneous, mediastinal and upper abdominal air with two areas of oral contrast focus: at the mid-oesophagus and 5 cm from gastroesophageal junction. The patient had a PSS score of 1.

Results: The patient was commenced on IV anti-microbials and IV proton pump inhibitor. On OGD, no evidence of a mucosal defect was found and dual nasogastric and nasojejunal tubes were placed for drainage and feeding. He remained Nil by Mouth (NPO) for 2 days and then diet progressed from fluids to solids. He was discharged when well and followed up in the clinic.

Conclusions: Iatrogenic perforations can be confidently managed conservatively, using risk stratification scores. Surgery remains an option in certain circumstances.

Keywords: Oesophagus; perforation; iatrogenic; conservative; management