Early Esophageal Perforation Due to a Large Impacted Food Bolus

Abstract

Purpose: Esophageal perforation is a rare complication of food impaction in the esophagus and is seen less than 1% of the time. The risk of esophageal perforation increases significantly after the first 24 hours secondary to transmural ischemia. We present an unusual case in which an esophageal perforation, that was sealed by the large food bolus, developed within a relatively short amount of time (6-8 hours) after the food impaction occurred. Results: A 38-year-old male with no past medical history presented to the ER with ongoing chest pain approximately six hours after eating a hot dog at a baseball game. He was unable to tolerate any oral liquids or his own saliva. He had no crepitus of the neck or chest and routine CXR was negative for signs of an esophageal perforation. He was taken for an emergent EGD approximately 9 hours post-ingestion and the examination showed an esophageal mucosa rent. The underlying muscularis propria was visualized without any manipulation of the food bolus. The examination was immediately terminated. Following the brief procedure, the patient proceeded to regurgitate the food bolus, which was an intact piece of hot dog about 5 cm in length, at which time the chest pain worsened. There was now palpable crepitus over the neck and upper chest supporting the diagnosis of an esophageal perforation. The patient was taken emergently to surgery and upon exposure of the mediastinum, there was evidence of a small abscess at the perforation site now just 12 hours post-ingestion. Conclusion: There have been few reports of early esophageal perforation due to food impactions in the abcense of an underlying risk factor. With longstanding impactions, the obstructing bolus can cause transmural inflammation and pressure necrosis of the adjacent esophageal wall leading to mucosal breakdown and an increased risk of perforation. We report a case in which a patient had spontaneous focal perforation of the esophagus without underlying risk factors such as eosinophilic esophagitis or excessive manipulation during the endoscopy, that appeared to have been sealed by the large food bolus until it was spontaneously dislodged. We believe that the large size of the bolus intact was able to exert higher than normal pressures on the esophageal wall leading to an extremely rapid progression of ischemia leading to wall necrosis and early perforation.