Complication of oesophagoscopy and anticoagulation

Abstract

Most reported injuries of the oesophagus are due to endotracheal intubation or oesophagoscopy.1 Procedures that involve intubation of the pharynx are commonly performed and currently anticoagulation is not thought to be a contra-indication. We highlight a case that may have been prevented, if anticoagulation had been stopped prior to the procedure. A 58-year-old man attended for an elective transoesophageal echocardiogram (TOE). Transthoracic echocardiography had previously been unrewarding due to large body habitus. The patient was anticoagulated with warfarin (chronic AF) and had a persistent cough. Coughing during oesophageal intubation forced the examination to be abandoned. On waking, the patient described pain in the left anterior neck. ENT identified a tender swelling in the left neck, left submucosal supraglottic swelling and dysphonia. A CT scan showed surgical emphysema and a 4-cm haematoma. His INR was 1.5 and warfarin was stopped, but not reversed. He was transferred to the ENT unit, where he was managed with steroids, antibiotics and fluids. His symptoms and signs resolved after several days and he was discharged uneventfully. Injuries to the pharynx and oesophagus may have life-threatening sequelae. In recent history, TOE is performed in anticoagulated patients during cardiac valve replacements, which may be more commonly seen in the future in an ageing population. This case raises interesting questions such as should anti-coag-ulated patients undergoing oesophagoscopy have their anticoagulation reversed (when medically safe)?2 Further, should we have a higher threshold for surgical intervention given the uncomplicated resolution of symptoms in this patient? Procedures involving pharyngeal intubation may be traumatic with potentially severe consequences but may be managed conservatively on occasion.