A Large Spontaneous Esophageal Perforation Treated With Endoscopic Stent Placement

Abstract

Esophageal perforations are extremely rare, with an incidence of 3.1 per 1,000,000 annually. About 15% are spontaneous, usually referred to as Boerhaave's syndrome, which occurs due to increased intraluminal pressure with inability of upper esophageal sphincter to relax during retching. However, a spontaneous perforation without such an inciting event is even more infrequent. An 88 year-old male with no prior medical history presented with chest pain, dyspnea and worsening acid reflux. Preliminary workup was concerning for a cardiac event, for which he underwent a cardiac catherization with stent placement. However, he continued to have chest pain, thus a CTA chest/abdomen/pelvis was performed, and revealed a likely hiatal hernia with significant reflux, however otherwise normal. Three days later a CXR showed a left pleural effusion, and eventually a CT chest revealed oral contrast in the left thorax with significant pneumomediastinum, suspicious for an esophageal perforation. He was transferred to the surgical ICU, kept NPO, started on empiric antibiotic, antifungal, and acid suppression therapy. The cardiothoracic surgical team placed two chest tubes. He then had an esophagram, showing a large esophageal defect with free extravasation of contrast into the mediastinum. Given that he was deemed a poor surgical candidate, he was taken to the OR for endoscopic stent placement. EGD revealed a large, 5cm perforation in the distal esophagus. No esophagitis or tumor was seen. Successful placement of two fully covered metal stents achieved adequate closure of the defect. Taking into account the lack of typical symptoms, typical inciting events, and overall patient tolerance of such a large perforation, this is a highly unusual case and suggests a possibly chronic underlying defect. Diagnosis of spontaneous esophageal perforation is often delayed as the classic triad of vomiting, chest pain and subcutaneous or mediastinal air, is only described in 50% of cases. Esophageal stents are an alternative to surgical treatment of perforations. Although esophageal stent placement successfully sealed the majority of our patients' perforation, a defect of this size will likely require surgical repair. This case emphasizes the importance of prompt recognition of a suspected esophageal perforation, the importance and diagnostic accuracy of CT scan with PO contrast and the potential role of fully covered metal stents as a therapeutic alternative to emergent surgery. Watch the video: https://goo.gl/fhkDGTFigure: CT chest/abdomen with IV and PO contrast demonstrating pneumomediastinum and oral contrast in the mediastinum.Figure: Fluoroscopic images from gastrograffin esophagram revealing large area of extravasation into the left mediastinum.